Efficacy of olaparib in advanced cancers with germline or somatic mutations in BRCA1, BRCA2, CHEK2 and ATM, a Belgian Precision tumor-agnostic phase II study

BACKGROUND

The Belgian Precision initiative aims to maximize the implementation of tumor-agnostic next-generation sequencing in patients with advanced cancer and enhance access to molecularly guided treatment options. Academic tumor-agnostic basket phase II studies are part of this initiative. The current investigator-driven trial aimed to investigate the efficacy of olaparib in advanced cancers with a (likely) pathogenic mutation (germline or somatic) in a gene that plays a role in homologous recombination (HR).

PATIENTS AND METHODS

This open-label, multi-cohort, phase II study examines the efficacy of olaparib in patients with an HR gene mutation in their tumor and disease progression on standard of care. Patients with a somatic or germline mutation in the same gene define a cohort. For each cohort, a Simon minimax two-stage design was used. If a response was observed in the first 13 patients, 14 additional patients were included. Here, we report the results on four completed cohorts: patients with a BRCA1, BRCA2, CHEK2 or ATM mutation.

RESULTS

The overall objective response rate across different tumor types was 11% in the BRCA1-mutated (n = 27) and 21% in the BRCA2-mutated (n = 27) cohorts. Partial responses were seen in pancreatic cancer, gallbladder cancer, endocrine carcinoma of the pancreas and parathyroid cancer. One patient with a BRCA2 germline-mutated colon cancer has an ongoing complete response with 19+ months on treatment. Median progression-free survival in responding patients was 14+ months (5-34+ months). The clinical benefit rate was 63% in the BRCA1-mutated and 46% in the BRCA2-mutated cohorts. No clinical activity was observed in the ATM (n = 13) and CHEK2 (n = 14) cohorts.

CONCLUSION

Olaparib showed efficacy in different cancer types harboring somatic or germline mutations in the BRCA1/2 genes but not in ATM and CHEK2. Patients with any cancer type harboring BRCA1/2 mutations should have access to olaparib.

PRECISION: the Belgian molecular profiling program of metastatic cancer for clinical decision and treatment assignment

PRECISION is an initiative from the Belgian Society of Medical Oncology (BSMO) in collaboration with several stakeholders, encompassing four programs that aim to boost genomic and clinical knowledge with the ultimate goal to offer patients with metastatic solid tumors molecularly guided treatments. The PRECISION 1 study has led to the creation of a clinico-genomic database. The Belgian Approach for Local Laboratory Extensive Tumor Testing (BALLETT) and GeNeo studies will increase the number of patients with advanced cancer that have comprehensive genotyping of their cancer. The PRECISION 2 project consists of investigator-initiated phase II studies aiming to provide access to a targeted drug for patients whose tumors harbor actionable mutations in case the matched drug is not available through reimbursement or clinical trials in Belgium.

Oncological patients' reactions to COVID-19 pandemic: A single institution prospective study

Background

The spread of the COVID‐19 pandemic has led to a rapid reorganization in all human and hospital activities, with impact on cancer patients.

Aim

An analysis of cancer patients fears, and awareness of COVID‐19 has been done in this study.

Methods and results

We analyzed cancer patients' reactions to the pandemic and their perception of oncological care reorganization, through a 12‐item survey, proposed at the peak of pandemic and 3 months later. Overall, 237 patients were included in the study. During the peak of pandemic 34.6% of patients were more worried about COVID‐19 than cancer versus 26.4% in the post‐acute phase (p = .013). Although 49.8% of patients in the acute phase and 42.3% in the post‐acute phase considered their risk of death if infected ≥50%, and more than 70% of patients thought to be at higher risk of complications, the majority of them did not consider the possibility to stop or delay their treatment. Patients were more interested in following news about COVID‐19 than cancer and they complied with all preventive measures in more than 90% of the cases.

Conclusions

Although cancer patients worried about COVID‐19 and evaluated the risk of complication or death due to COVID‐19 as extremely high, they were still asking for the best oncological treatment.

[Neuroendocrine neoplasms : a new era to the top of multidisciplinarity !]

Neuroendocrine neoplasms are histologically defined by a common neuroendocrine cellular phenotype. These are still considered as rare tumours even though their incidence is increasing. Heterogeneity is everywhere whether in the localization of the primitive cancer, the clinical presentation, the histological classification, the prognosis, as well as in therapeutic options, which clearly justifies specialized multidisciplinary care. Heterogeneity and scarcity explain the still fragmented nature of knowledge in this domain. Thanks to an increase in incidence, a desire for standardization of classification as well as the arrival of major therapeutic advances, such as vectorized internal radiotherapy, the future of neuroendocrine neoplasia seems more than promising and exciting. In our daily clinical practice at CHU Liège, we hope to bring our stone to the building by listing as many cases as possible in national and/or international databases, by centralizing therapeutic discussions within specific multidisciplinary concertations and by participating in multicenter study protocols.

[Multidisciplinary management of the primary liver cancers]

In Belgium and around the world, the incidence of primary malignant liver tumours is increasing, both for hepatocarcinoma and cholangiocarcinoma. Their curative treatment is based on multidisciplinary and specialized care, of which surgery (including liver transplantation) remains the cornerstone, often associated with other logoregional treatments, as radioembolisation, radiofrequency ablation, and chemoembolisation. For advanced cases, the prognosis remains poor, in particular due to a certain chemoresistance of these tumours. New treatments include targeted therapies (including various tyrosine kinase inhibitors) and immunotherapy. A specialized multidisciplinary discussion is therefore necessary to define the best therapeutic management, individualized to each patient. In this article, the authors review the most recent data relating to the treatment of hepatocarcinoma and cholangiocarcinoma.

[Treatment of mucocutaneous toxicity of target therapy in oncology]

The spectrum of the mucocutaneous adverse effects of directed oncologic therapies, such as anti-EGFR, anti-VEGF, anti-TK and anti-BRAF, presents similarities but also differences compared to that of the classic chemotherapeutics. This article reviews the dermatological toxicities of the targeted therapies, with 11 clinical cases, including mucositis and oral toxicities, the acne-like eruptions, nail changes and complications, the «hand/foot» syndrome, radiosensitization, alopecias, xerosis and skin fissures. After a brief clinical case presentation and theoretical issues, the clinical management is discussed in detail.

WITHDRAWN: A single center experience in resectable pancreatic ductal adenocarcinoma : the limitations of the surgery-first approach. Critical review of the literature and proposals for practice update

The article has been withdrawn at the request of the authors and editor because of incorrect authorship, which is considered a form of unethical publication. The Publisher apologizes for any inconvenience this may cause.

Transcriptome-wide analysis of natural antisense transcripts shows their potential role in breast cancer

Non-coding RNAs (ncRNA) represent 1/5 of the mammalian transcript number, and 90% of the genome length is transcribed. Many ncRNAs play a role in cancer. Among them, non-coding natural antisense transcripts (ncNAT) are RNA sequences that are complementary and overlapping to those of either protein-coding (PCT) or non-coding transcripts. Several ncNATs were described as regulating protein coding gene expression on the same loci, and they are expected to act more frequently in cis compared to other ncRNAs that commonly function in trans. In this work, 22 breast cancers expressing estrogen receptors and their paired adjacent non-malignant tissues were analyzed by strand-specific RNA sequencing. To highlight ncNATs potentially playing a role in protein coding gene regulations that occur in breast cancer, three different data analysis methods were used: differential expression analysis of ncNATs between tumor and non-malignant tissues, differential correlation analysis of paired ncNAT/PCT between tumor and non-malignant tissues, and ncNAT/PCT read count ratio variation between tumor and non-malignant tissues. Each of these methods yielded lists of ncNAT/PCT pairs that were enriched in survival-associated genes. This work highlights ncNAT lists that display potential to affect the expression of protein-coding genes involved in breast cancer pathology.

A single center experience in resectable pancreatic ductal adenocarcinoma : the limitations of the surgery-first approach. Critical review of the literature and proposals for practice update

BACKGROUND AND STUDY AIMS

The current standard of care for resectable pancreatic ductal adenocarcinoma (PDAC) is surgery-first followed by adjuvant chemotherapy. We review our single center experience in a PDAC cohort managed by the surgery-first strategy. We then compare our data to those of Belgian and international literature.

PATIENTS METHODS

We reviewed a series of 83 consecutive resectable patients with PDAC, treated by the surgery-first approach in a Belgian Academic Hospital between 2007 and 2013. The outcomes were assessed with univariate and multivariate Cox regression analysis. Kaplan-Meier curves were drawn according to patient groups.

RESULTS

For the entire population, the median survival (MS) was 18.4 months; the 1-year relapse-free survival was 56%, and the 5-year overall survival (OS) was 13%. The size of the primary tumor larger than 3 cm (OS, HR = 1.76, p = 0.033) and vascular resection (DFS, HR = 2.1, p = 0.024) were the single independent prognostic factors in the multivariate analysis of this cohort. Only 69% of the patients received adjuvant chemotherapy, and more than 75% of them demonstrated no chance of survival beyond 3 years because they harbored poor prognostic factors, recognized only postoperatively.

CONCLUSIONS

Our results and those published in the literature brought to light the limited perspectives of the surgery-first strategy in a population of apparently resectable pancreatic cancers. In comparison, data from reported neo-adjuvant series deserve our interest to bring this strategy upfront in selected patients in the context of close observational monitoring and randomized trials. The actual standard of care for resectable PDAC is surgery-first followed by adjuvant chemotherapy. The performance of this strategy relies on the dedicated imaging that does not accurately recognize the limits of the tumor and the high prevalence of adverse prognostic factors. Moreover, pancreatectomy remains associated with high postoperative complication rates and the poor completion of adjuvant therapy. This translates into poor long-term survival figures. In our series the MS was 18.4 months and 5-year OS was 13%. The disease-free survival (DFS) was 15.6 months, 1 and 3-year DFS were 56 and 26%, respectively. The variables that significantly correlated with OS in univariate analysis are tumor size and lymph node involvement. Regarding DFS, vascular resection was the only significant factor. In the multivariate analysis, the only significant factor related to OS remained the tumor size >3 cm in greatest diameter. Vascular resection remained significant for DFS. 31% of the patients did not receive any chemotherapy at all before the 6-month period following resection. The rates of complete resections compared favorably with those of a surgery-first strategy with no excess of operative mortality, complications and early relapse rates. The advantages of a chemotherapy-first approach, eventually combined with chemo-radiotherapy, are to offer higher combined therapy completion rates and improve the level of free resection margins, lymph node involvement and patient selection. The advent of safe, more potent chemotherapy combinations has the potential to further improve survival when administered upfront.

[Comprehensive therapeutic strategy for localized esophageal cancer. Second part : interest of multimodal approaches with or without surgery]

In recent years, the treatment of esophagus cancer has been completely changed, thus competing the dogma of surgery as the cornerstone treatment. Multimodality treatments as radio-chemotherapy directly followed by surgery, or delayed surgery, significantly improve patient survival compared to surgery alone. Neoadjuvant radiochemotherapy is associated with a higher complete pathologic response rate and improved survival compared to chemotherapy alone. Immediate surgery after radio-chemotherapy is challenged for patients who present a complete clinical response, especially in case of squamous cell carcinoma. Indeed, systematic resection is associated with a significant postoperative mortality rate and has not proven any survival advantage in complete clinical responders as opposed to delayed resection in case of locally persistent or recurrent disease. In squamous cell carcinoma, this could lead to organ preservation, thus avoiding the mortality and durable functional impairment of esophagectomy. This review will discuss the positioning of the multimodality treatment strategy with neoadjuvant radiochemotherapy and chemotherapy and also the strategy of organ preservation.

[Comprehensive therapeutic strategy for localized esophageal cancer]

Esophageal cancers represent a highly heterogeneous entity mixing two different tumour types : AdenoCarcinoma (ADC) and Squamous Cell Carcinoma (SSC). Developing in the same organ, they are very often considered as a unique pathology and, consequently, the same therapeutic strategy is indiscriminately applied. Esophageal cancer treatments are particularly complex and require a multidisciplinary approach. Despite impressive advances in the tumour statidifaction, surgery, radiotherapy and chemotherapy, the overall prognosis remains grim even at an early stage of the disease. In order to improve the treatment of esophageal cancers and the patient’s survival, we need to consider that ADC and SCC represent two different pathologies requiring specific therapeutic strategies. This review in two parts will present recent data from clinical trials under the scope of tumour histology to set up dedicated therapeutic strategies. In this first part, we explain the restricted role of surgical resection, the prognostic factors and the results of exclusive combined chemotherapy and radiation in localized esophageal cancer.

Circulating microRNA-based screening tool for breast cancer

Circulating microRNAs (miRNAs) are increasingly recognized as powerful biomarkers in several pathologies, including breast cancer. Here, their plasmatic levels were measured to be used as an alternative screening procedure to mammography for breast cancer diagnosis.

A plasma miRNA profile was determined by RT-qPCR in a cohort of 378 women. A diagnostic model was designed based on the expression of 8 miRNAs measured first in a profiling cohort composed of 41 primary breast cancers and 45 controls, and further validated in diverse cohorts composed of 108 primary breast cancers, 88 controls, 35 breast cancers in remission, 31 metastatic breast cancers and 30 gynecologic tumors.

A receiver operating characteristic curve derived from the 8-miRNA random forest based diagnostic tool exhibited an area under the curve of 0.81. The accuracy of the diagnostic tool remained unchanged considering age and tumor stage. The miRNA signature correctly identified patients with metastatic breast cancer. The use of the classification model on cohorts of patients with breast cancers in remission and with gynecologic cancers yielded prediction distributions similar to that of the control group.

Using a multivariate supervised learning method and a set of 8 circulating miRNAs, we designed an accurate, minimally invasive screening tool for breast cancer.

[Carcinoma of unknown primary : a not so rare entity]

Carcinomas of unknown primary (CUP) form a whole group of heterogeneous neoplasias. CUP are defined as metastatic epithelial tumors in which the initial work up has failed to detect the primary site. Their frequency is 3-5 % of the adult solid neoplasias. The prognosis is poor with a life expectancy of a few months (inferior to 1 year). The treatment depends on the histology and, particularly, on the metastatic localiza¬tion. Surgery with or without radiotherapy is the preferred treatment option for isolated lesions. Systemic chemotherapy (with platinum compound) will be recommended for multiple lesions. The genetic expression profile of tumor cells could be useful in the future to determine the site of the primary tumor and/or to offer the best therapy for each patient.

Resistance to therapy in estrogen receptor positive and human epidermal growth factor 2 positive breast cancers: progress with latest therapeutic strategies

In this article, we focus on the subtype of estrogen receptor (ER)-positive, human epidermal growth factor 2 (HER2)-positive breast cancer (BC). Preclinical and clinical data indicate a complex molecular bidirectional crosstalk between the ER and HER2 pathways. This crosstalk probably constitutes one of the key mechanisms of drug resistance in this subclass of BC. Delaying or even reversing drug resistance seems possible by targeting pathways implicated in this crosstalk. High-risk patients currently receive anti-HER2 therapy, chemotherapy and endocrine therapy in the adjuvant setting. In metastatic cases, most patients receive a combination of anti-HER2 therapy and chemotherapy. Only selected patients presenting more indolent disease are candidates for combinations of anti-HER2 therapy and endocrine therapy. However, relative improvements in progression-free survival by chemotherapy-based regimens are usually lower in ER-positive patients than the ER-negative and HER2-positive subgroup. Consequently, new approaches aiming to overcome endocrine therapy resistance by adding targeted therapies to endocrine therapy based regimens are currently explored. In addition, dual blockade of HER2 or the combination of trastuzumab and phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOP) inhibitors targeting the downstream pathway are strategies to overcome resistance to trastuzumab. This may lead in the near future to the less frequent use of chemotherapy-based treatment options in ER-positive, HER2-positive BC.

Triple-negative breast cancer: treatment challenges and solutions

Triple-negative breast cancers (TNBCs) are defined by the absence of estrogen and progesterone receptors and the absence of HER2 overexpression. These cancers represent a heterogeneous breast cancer subtype with a poor prognosis. Few systemic treatment options exist besides the use of chemotherapy (CT). The heterogeneity of the disease has limited the successful development of targeted therapy in unselected patient populations. Currently, there are no approved targeted therapies for TNBC. However, intense research is ongoing to identify specific targets and develop additional and better systemic treatment options. Standard adjuvant and neoadjuvant regimens include anthracyclines, cyclophosphamide, and taxanes. Platinum-based CT has been proposed as another CT option of interest in TNBC. We review the role of this therapy in general, and particularly in patients carrying BRCA germ-line mutations. Available data concerning the role of platinum-based CT in TNBC were acquired primarily in the neoadjuvant setting. The routine use of platinum-based CT is not yet recommended by available guidelines. Many studies have reported the molecular characterization of TNBCs. Several actionable targets have been identified. Novel therapeutic strategies are currently being tested in clinical trials based on promising results observed in preclinical studies. These targets include androgen receptor, EGFR, PARP, FGFR, and the angiogenic pathway. We review the recent data on experimental drugs in this field. We also discuss the recent data concerning immunologic checkpoint inhibitors.

Chemotherapy options for patients suffering from heavily pretreated metastatic breast cancer

The identification of additional chemotherapy agents for anthracycline- and taxane-pretreated advanced breast cancer (ABC) is an urgent medical need. Single agent chemotherapy is most times administered because combined therapy is only associated with modest, if any, improvement in median progression-free survival. Randomized trials failed to show overall survival benefit compared with single agent chemotherapy. We hope to modify the natural history of ABC by the consecutive use of treatments with documented activity in heavily pretreated patients. Quality of life remains an important end point as cure is in general not possible. We first review the activity of the approved and the most frequently used agents in heavily pretreated ABC. Thereafter, the potential role and safety profile of etirinotecan pegol is discussed given the results recently released of a Phase III trial comparing this agent to Treatment of Physician's Choice.

[Biopsy of suspicious lesions in patients with breast cancer]

Discordances between hormone receptors and HER2 status in primary and metastatic breast cancer have been reported by several studies. In this context, systematic biopsies could be clinically relevant in breast cancer to confirm the biological characteristics of a suspicious lesion. In this article, illustrated by 2 case reports and based on a recent review on this topic, we discuss the clinical significance of receptor discordances and possible diagnosis of a secondary primary tumor. The role of these biopsies for the identification of new therapeutic targets is also envisaged as well as underlying mechanisms for receptors' modification like tumoral heterogeneity, clonal selection and technical artifacts.

[CRITICAL VIEWPOINT ON THE CURRENT APPROACH OF LOCALIZED PANCREATIC DUCTAL ADENOCARCINOMA]

Surgical resection followed by chemotherapy is the actual standard of care for localized, deemed resectable, pancreatic ductal adenocarcinoma. Despite a better selection of surgical candidates and the actual performance of expert teams, the proportion of patients with a prolonged survival has not been ameliorated during the last three decades. The morphological determinants of resectability are the subject of limitations. In the future, only a better understanding of the biological process, an earlier diagnosis of purely localized disease and more efficient systemic therapies may lead to a better prognosis. Meanwhile, taking into account the prognostic factors associated with a lower chance of cure is currently a matter of debate. The optimal therapeutic sequence, being a surgery-first or a neoadjuvant approach is controversial. The theoretical advantages of preoperative chemotherapy eventually associated with chemo-radiation are demonstrated in other tumours and applicable to pancreatic cancer without any excess of operative mortality, early progression rates and, on the contrary with positive survival data. The completion rates of multi-modal therapy are in favour of the preoperative approach, which also gives the opportunity to select the best candidates for surgical resection.

[Evolution in the therapeutic strategy of localized resectable pancreatic ductal adenocarcinoma]

Pancreatic ductal adenocarcinoma is characterized by a high rate of early metastatic relapse. Surgical resection is still recognized as the cornerstone upfront therapy. However, reported 5 years survival rates are inferior to 20-25% even when surgery is followed by chemotherapy. Margins involvement on the surgical specimen (50 to 85%) and lymph node involvement (around 70%) both strongly impact survival. Median survivals are close to those of locally advanced diseases treated by chemotherapy or chemoradiotherapy, 15 to 16 months. This review focuses on adverse prognostic factors, post-operative outcomes and their impact on multimodality therapy completion rates and survivals in patients undergoing upfront surgery. Current data and emerging results from neoadjuvant series could lead to a change in the therapeutic strategy.

[BREAST CANCER: FROM TARGETED THERAPY TO PRECISION MEDICINE]

The authors review the principles of systemic therapy in breast cancer. They analyze the degree of treatment individualization in our current approach. New technologies allow the detection of genomic alterations in cancer cells. Unfortunately, we do not know yet how to best use this knowledge for routine patient care. Most genomic alterations are rare events complicating further drug development. Temporal and spatial heterogeneity in tumors also has to be taken into account. An intense international collaboration is ongoing to try and demonstrate that precision medicine will really improve treatment outcome.

[Management of febrile neutropenia in cancer patients]

The incidence of cancer is raising and the treatments are increasingly aggressive. Consequently, general practitioners, emergency departments, hematologists and oncologists are regularly facing a severe side-effect of cytotoxic therapy, febrile neutropenia (FN). FN is a serious complication of chemotherapy because it can be quickly fatal and causes a temporary or definitive cessation of treatment. In this article, we summarize the latest recommendations for the management of patients with FN under anti-cancer treatments.

[The drug of the month: everolimus (Afinitor) for the treatment of metastatic breast cancer]

Sequential endocrine treatments are recommended for estrogen receptor (ER) positive human epidermal growth factor receptor 2 (HER 2) negative metastatic breast cancers except in the case of symptomatic visceral disease. However, patients who suffer from disease progression while receiving a non-steroidal aromatase inhibitor (NSAI) have a very poor prognosis with standard endocrine therapy alone. Recently, based onthe results of the BOLERO 2 trial, the mammalian target of rapamycin (mTOR) inhibitor everolimus, combined with exemestane, a steroidal aromatase inhibitor, has been approved in Europe and the US for patients suffering from ER positive HER2 negative advanced breast cancer previously treated by a NSAI. The median progression-free survival (PFS) increased from 3.2 to 7.8 months in patients receiving everolimus and exemestane compared to placebo and exemestane. The magnitude of benefit was consistent in all pre-specified subgroups. Side effects were manageable and the quality of life was at least maintained. Everolimus has also beenrecently studied in HER2 positive locally advanced or metastatic disease in heavily pretreated patients (BOLERO 3 trial). This trial met its primary endpoint. The median PFS was increased in patients receiving trastuzumab, vinorelbine and everolimus compared to patients receiving trastuzumab, vinorelbine and placebo. We review pharmacological data and side effects of the drug. We also review the most important clinical trials leading to reimbursement of everolimus in metastatic breast cancer.

[Radiotherapy for elderly patient with rectal cancer: which benefit?]

Age acts as a major risk factor of cancer. In the near future, with the aging of the population, we will treat more and more elderly patients with oncologic disease. Unfortunately, these patients are often excluded from randomized trials. How can we, therefore, define guidelines for this particular population of patients? Moreover, older patients often present multiple morbidities synchronously with the oncologic disease. This constellation of diseases makes the therapeutic strategy even more difficult. The highest incidence of rectal cancer is observed at 80 years old or above. This is significantly older than the mean age of the population included in clinical trials. Although, the prognosis of young patients with rectal cancer has improved over the past few decades, this is not the case for patients over 75 years old. A geriatric evaluation, as a part of a multidisciplinary approach, may allow to better select patient able to benefit from a combined treatment. Radiotherapy plays a crucial role in the treatment of rectal cancer. There are no solid data currently available on the real impact of radiotherapy on survival in an elderly population with rectal cancer. Do these patients really benefit from this treatment and what is the impact of radiotherapy on their quality of life? This review will try to give some answers to these important questions.

[Radiotherapy in rectal cancer: when, why and how?]

Since several decades, radiotherapy plays a crucial role in the management and local control of the rectal adenocarcinoma. The local recurrences pattern of the rectal tumor has completely changed with the systematic use of the Total Mesorectal Excision surgery (TME). In this context, the rate of radiotherapy needs to be reviewed. In this article we propose an overview of the main studies using radiotherapy in a pre- or post-operative setting in the context ofTME surgery. This will help to better define the indications of radiotherapy in rectal cancer.

[Will targeted therapies replace chemotherapy?]

The oncologist dream is to provide more benefit with lower toxicity. The increasing knowledge of molecular mechanism for survival and proliferation of cancer cells leads to the development of targeted therapies with impressive results for some cancers even if not associated with chemotherapy. These targeted treatments could be monoclonal antibodies or tyrosine kinase inhibitors. Inactivation of only one oncogene can lead to the regression of tumours as well as the inhibition of only one pathway with one or more inhibitors. This result is related to the oncogenic addiction of these tumours. Examples are imatinib in CML and GIST, trastuzumab in HER2 positive breast cancer, gefitinib in mutated EGFR, crizotinib in EML4-ALK positive lung cancer and, also, vemurafenib in BRAF 600E mutated metastatic melanoma. We shall specifically discuss HER2 positive breast cancer, which represent some 15-20% of breast cancers and the recent targeted and bi-targeted therapies. Trastuzumab, an anti-HER2 monoclonal antibody has changed the prognosis of the disease improving survival in the metastatic and adjuvant setting. Lapatinib, a dual tyrosine kinase inhibitor of EGFR and HER2 is approved with capecitabine in trastuzumab resistant patients and in combination with letrozole in first line. Unfortunately, 20% of patients receiving adjuvant trastuzumab relapse and metastatic patients only transienly respond to trastuzumab or lapatinib combined with chemotherapy. New HER2 targeted drugs are currently in development like pertuzumab, T-DMI or mTOR and PI3K inhibitors. New strategies combining these drugs with or without chemotherapy showed interesting results in metastatic and neoadjuvant trials. The selection of patients who will most benefit from these combinations is still a challenge. Currently, chemotherapy in association with anti-HER2 therapy remains the most effective treatment option.

[Breast cancer in young women]

The outcome of very young patients with early breast cancer is worser compared to older patients with a similar clinical presentation. The triple negative, luminal B, HER2+ subtypes are more frequent in this population. Adequate local treatment (breast-conserving surgery or total mastectomy) must be discussed with the patient. The role of radiotherapy is very important in these patients with high risk of local recurrence. The progress in adjuvant treatment of very young patients requires studies of tailored treatments.

[Hormone therapy for breast cancer]

Following Beatson's publications in 1896, various modalities of endocrine therapy applied to breast cancer have been developed. Endocrine treatment has greatly contributed to the improvement of the disease's prognosis. Tamoxifen has established itself as a first choice adjuvant therapy for patients with tumors expressing hormone receptors. Over the last decade, third generation aromatase inhibitors have demonstrated their efficacy amongst menopausal patients, alone or in combination with tamoxifen. Efficacy of these medications is dependent on patient's compliance. This article proposes a synthesis of the main knowledges available in the field of breast cancer endocrine therapy.

[Molecular and genetic aspects of triple negative breast cancer and therapeutic implications]

Triple negative breast cancers are defined by the lack of expression of estrogen, progesterone and HER2 receptors. They represent an heterogeneous population with poor prognosis. The treatment of these tumors is a challenge because there is no known specific target. A huge number of studies try to better characterise these tumors at the molecular level with the aim to identify new therapeutic targets. The finding of new specific biomarkers like intracellular and extracellular microRNAs is also an important field of research. This article reviews some recent data in this field and the research on different pathways for the development of new therapies.

[Single cervical metastasis of breast cancer]

We report a rare case of single cervical metastasis of breast cancer. Bone metastases are the most frequent in breast cancer. Early diagnosis combined with the new therapeutic advances have considerably improved the quality of life and increased the survival. Imaging plays a great role in the diagnosis, particularly scintigraphy and radiography, but sometimes also CT and MRI. The treatment is currently not standardized and it combines hormone therapy, chemotherapy, radiotherapy, and/or surgery.

[Targeted therapies in breast cancer]

The better understanding of the biology of breast cancer has allowed the identification of new targets for anticancer therapy. Trastuzumab, a monoclonal antibody binding the HER2 receptor, is used since several years in the treatment of HER2 overexpressing breast cancer, including in the adjuvant setting. Lapatinib, a tyrosine kinase inhibitor, was introduced more recently into the clinic. New treatment options under evaluation in HER2 overexpressing breast cancer include combinations of anti-HER2 treatments, drugs targeting the downstream signaling pathway and new anti-HER2 agents such as pertuzumab and T-DM1. This article also reviews other targeted treatments of interest in the field of breast cancer including antiangiogenic agents and drugs targeting the PI3K-AKT-mTOR pathway.

[Systemic chemotherapy and breast cancer]

Breast cancer mortality is decreasing, partly due to better adjuvant treatments with new drugs and new schedules. In Belgium, the overall survival is 76%. Chemotherapy is still an important treatment option. We need to better select patients who really will benefit from treatment in order to decrease toxicity and improve long term outcome.Targeting the specific population is now a priority. Prognostic and predictive factors will enable us to better define the sub-population of patients most benefiting from treatment. We will also discuss the knowledge of systemic treatment. When we have to decide wether chemotherapy is indicated, we need to well balance the treatment risks and benefits because gain in survival is important but reducing short and long term toxicity is also a challenge.

[Radiotherapy in breast cancer: current standards of treatment, prediction of local recurrence and open questions]

Adjuvant radiotherapy after surgery is a ("well-established standard" in routine clinical practice for breast cancer. Nevertheless, a variety of questions still remain unanswered. We intend to illustrate the overall importance of radiotherapy in breast cancer and highlight some unresolved questions by quoting presentations recently made at ASTRO-2010. More and more emphasis is put on the idea of an individual approach. Predicting the individual local recurrence risk is the search for the "Holy Grail". Methods such as nomograms and genomic profiling are currently tested but need to be validated before their widespread clinical application.

[Breast cancer and brain metastases]

The cerebral metastases are frequent in the evolution of breast cancer and convey a poor prognosis. The frequency depends on the histology of the cancer and on the expression of oestrogen and progesterone receptors as well as of HER2 antigen. The treatment is currently based on surgery and the different modalities of radiotherapy used alone or in association. Indeed, chemotherapy agents available for the treatment of breast cancer do not cross the hematoencephalic barrier and are thus ineffective. However, some encouraging results have been recently reported with the therapies targeting HER2.

[Heterogeneity of bone metastases in a patient with breast cancer: case report illustrating the potential of combining various imaging techniques]

Morphological appearance of bone metastases in breast cancer can be classified into three groups: osteolytic, sclerotic and mixed types. 18F-NaF PET/CT is considered to be superior to bone scintigraphy (BS) for the detection of bone metastases. 18F-NaF PET shows a higher uptake in both lytic and sclerotic bone metastases with a higher contrast and spatial resolution than BS. 18F-FDG PET is generally considered to be superior to BS for detection of lytic bone metastases. However, BS and 18F-NaF PET/CT are more sensitive for sclerotic lesions, as a decreased 18F-FDG uptake in this subtype of lesion has been reported. In conclusion, as various types of bone metastases may coexist in a single patient, the combination of both 18F-FDG and 18F-fluoride PET/CT studies is likely to provide the most comprehensive assessment of metastatic spread to the skeleton.

[Late relapse of breast cancer after adjuvant chemotherapy]

Late relapses (> 10 years) of breast cancer are mainly observed in ER positive tumors. The yearly relapse rate is still 0.5 % after 10 years. These relapses occurred even if adjuvant chemotherapy was given. Consequently, a better knowledge of the metastatic process is warranted in order to define better treatment options. We will discuss here a case of hormonosensitive breast cancer relapsing 20 years after the initial treatment. We will discuss the most recent data concerning late relapses. New hypotheses concerning disseminated tumoral cells and circulating cells will be reported. We will also review data about stem cells, tumor initiating cells and dormancy state.

[Imaging bone metastases in breast cancer]

Breast cancer is the most common female malignancy and bone is the most common site of distant metastases. Early detection and accurate assessment of bone involvement is needed to optimize treatment and therefore reduce or delay skeletal-related events. We discuss the different bone imaging modalities with emphasis on nuclear medicine techniques. Currently, whole body bone scintigraphy (BS) is recommended in selected patients at high risk of bone metastases (BM). New hybrid cameras combining 3-D scintigraphic images and computed tomography (SPECT/CT) improve diagnostic accuracy of BS. The 2-deoxy-2-[18F]fluoro-D-glucose (FDG) positron emission tomography (PET) seems to exhibit higher specificity and accuracy to detect BM in breast cancer. FDG PET/CT could be a useful tool for monitoring the effectiveness of treatment of breast cancer BM. Recent whole-body magnetic resonance imaging (MRI) techniques could become an additional tool to assess bone involvement from breast cancer. No consensus has been yet established regarding the best modality for diagnosing breast cancer BM and for assessing its response to treatment. The best approach is probably the combination of the different imaging modalities knowing the strengths and weaknesses of each technique.

[Circulating tumor cells: detection, characterization and clinical impact]

The metastatic process generates circulating tumor cells (CTCs) and disseminated tumor cells (DTCs) in bone marrow and other organs which can remain as occult metastases. Various methods and systems have been developed to allow the isolation and identification of those cells but major technical limitations still exist. Research on CTCs is a nevertheless tremendously growing field of cancer research because of their potential clinical applications. CTCs indeed convey predictive information for the development of metastasis and recurrence, and prognostic information regarding patient survival. CTCs enumeration could also be used to monitor the effectiveness of adjuvant treatments. Moreover, enhancing our basic understanding of the metastatic process, CTCs, and DTCs in particular, are thought to contain subpopulations of cells with stem cells properties that would be responsible for relapses.

[Breast cancer in the elderly patient]

There is no standard of care for breast cancer treatment in the elderly patient. Given the heterogeneity of this population, the treatment of both localized and metastatic disease, requires to take into account not only the characteristics of this cancer but also factors related to the patient such as co-morbidities, life expectancy and the social environment.

Assessment of Response to Therapy for Bone Metastases: Is it Still a Challenge in Oncology?

Bone is one of the most common sites of metastases from cancer. Most anticancer treatments are highly toxic but only a fraction of all patients respond to them. Guidelines are needed to evaluate the response in the routine practice of oncology as well as in clinical trials in which new treatment options are evaluated. All current imaging procedures have major limitations. This article reviews old and new criteria for response evaluation. The major problem of accurate response evaluation in bone disease is discussed in detail. Some examples from our daily practice illustrate the difficulties. The indications for bone biopsy are also reviewed.

[Adherence to long-term medication: the particular case of the adjuvant endocrine therapy for breast cancer]

The aim of adjuvant hormone therapy for breast cancer is to reach, in daily practice, an efficacy similar to that obtained in clinical trials. In spite of the demonstrated efficacy of hormone therapy, compliance represents a major challenge and a multidimensional problem. A better understanding of the reasons underlying non-compliance would help identify the patients at higher risk and would permit the implementation of strategies to improve compliance to adjuvant hormone therapy. With this in mind, we undertook a review of the recent literature on the topic (Pub Med 2003-2009).

["Triple negative" breast cancer]

In western countries, every woman out of eight will develop breast cancer. Over the last two decades, the incidence has considerably increased, but mortality has remained stable and begins to decrease in Europe and the United-States, probably because of new therapy, changes in the use of hormone replacement therapy in postmenopausal women and early diagnosis. Breast cancer is still the first cause of death by cancer in woman under 65. "Triple negative" a breast cancer, a subtype representing 10% of all breast cancers, is characterised by the absence of receptors to oestrogen, progesterone and no histochemical expression of HER-2 growth factor. This subtype carries a poor prognosis and a high incidence of early metastatic recurrence. Furthermore, no target therapy can be defined up to now in this subtype. Thus, identification of new target therapy and prediction of tumoral response to various treatments could help in the global understanding of patients affected by this particularly aggressive type of breast cancer.

[Hypofractionated postoperative radiotherapy for breast cancer]

Postoperative adjuvant radiotherapy for breast cancer is usually applied in twenty five fractions of 2 Gy on the whole breast followed by a boost dose on the initial tumour site. Facing a continuous rise of the workload in radiotherapy departments, investigators have tried to reduce the burden of such a treatment approach both for the patients and the departments as available resources are not unlimited. These hypo-fractionated treatment schedules have been tested and validated in randomized controlled trials. Based on this evidence a new treatment algorithm has been built up as it has been shown that those schedules do provide similar levels of local control with comparable or an even lower risk of toxicity.