A multi-institutional analysis of intraoperative radiotherapy for early breast cancer: Does age matter?

BACKGROUND

Single-session intraoperative radiation therapy (IORT) minimizes treatment demands associated with traditional whole breast radiation therapy (WBRT) but outcomes on local disease control and morbidity among the elderly is limited.

METHODS

A multi-institutional retrospective registry was established from 19 centers utilizing IORT from 2007 to 2013. Patient, tumor, and treatment variables were analyzed for ages <70 and ≥70.

RESULTS

We evaluated 686 patients (<70 = 424; ≥70 = 262) who were margin and lymph node negative. Patients <70 were more likely to have longer operative time, oncoplastic closure, higher rates of IORT used as planned boost, and receive chemotherapy and post-operative WBRT. Wound complication rates were low and not significantly different between age groups. Median follow-up was 1.06 (range 0.51-1.9) years for < 70 and 1.01 (range 0.5-1.68) years for ≥ 70. There were 5 (0.73%) breast recurrences (4 in <70 and 1 ≥ 70, p = 0.65) and no axillary recurrences during follow-up.

CONCLUSIONS

IORT was associated with a low rate of wound complication and local recurrence on short-term follow-up in this cohort.

Abstract P3-14-14: Neoadjuvant phase II trial with carboplatin and eribulin in triple negative breast cancer patients

Background:

Several neoadjuvant trials have been conducted directed at treating triple negative breast cancer (TNBC) patients with platinum agents with pathologic complete response (pCR) rates ranging from 16%-32%. Eribulin mesylate, a nontaxane microtubule dynamics inhibitor with a novel mechanism of action, has clinical activity as monotherapy in breast cancer and other solid tumors. A recent phase I trial found that the combination of eribulin mesylate with carboplatin was well tolerated and showed activity in advanced solid tumors. The recommended dose for future trials was eribulin mesylate 1.1 mg/m2 and carboplatin AUC6. We proposed a neoadjuvant phase II trial with the combination of carboplatin and eribulin in patients with TNBC.

Methods:

30 patients were enrolled between November 2011 and February 2013. Patients received eribulin at 1.4 mg/m2 (intravenously over 2-5 minutes) on days 1 and 8 followed by carboplatin AUC = 6 (intravenously over 30 minutes) on day 1 every 21 days for a total of 4 cycles. Definitive surgery was performed 3-8 weeks after completion of therapy.

Our primary endpoint was to determine the pCR in TNBC patients treated with the combination of carboplatin and eribulin. Secondary objectives included determination of the clinical response rate, residual cancer burden (RCB), toxicity evaluation, in addition to correlative markers including TLE3, Smad3, cyclins/CDKs, and PIN1 and the Homologous Recombination Deficiency Assay (HRD).

Results:

There was an initial safety run-in to evaluate the appropriate dose of eribulin in the study population. After the 10th patient, the study was temporarily suspended; toxicity was assessed for the first 10 patients (cycle 1 only) to assess whether eribulin at 1.4mg/m2 or a dose reduction to 1.1 mg/m2 would be required for the remaining patients. Of the first 10 patients, only 2 of 10 experienced grade 3 or 4 neutropenia, and 0 of 10 patients experienced grade 3 or 4 peripheral neuropathy. Therefore, the study was continued for the remaining 20 patients with eribulin dosed at 1.4 mg/m2 and carboplatin AUC = 6.

Thirty of the planned 30 patients have been enrolled to date. Of the 30 patients, 24 have completed therapy and 6 are currently on study. Of the 24 patients who have completed therapy, 11 have achieved a pCR (45.83%). As for clinical response rates, 5 have had stable disease (20.8%), 5 have had a complete response (20.8%), and 13 have had a partial response (54.2%). Final results will be presented at the time of the meeting including pCR, RCB, toxicity and correlative studies.

The combination of eribulin and carboplatin was well tolerated with a predictable side effect profile. Of the 24 patients who have completed therapy, 8 (33%) required a dose reduction in eribulin for grade 3 or 4 neutropenia. One patient had neutropenic fever. There were no dose reductions for thrombocytopenia thus far. Correlative studies are in progress.

Conclusion:

The combination of carboplatin and eribulin in the neoadjuvant setting appears to be safe and efficacious in patients with TNBC. Statistical analysis on outcomes for the entire study population and correlative study results on pre- and post-treatment tissues are forthcoming. Future randomized clinical trials should evaluate further this regimen.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-14-14.

Breast cancer characteristics in yielders and nonyielders of nipple aspiration fluid

71

Background: Nipple aspirate fluid (NAF) is an attractive biosample for the investigation of breast cancer risk factors. The reported NAF yield rate varies from 30% to 90% in various studies, raising questions about its value as a risk assessment and about the generalizability of data generated in NAF-yielders to non-yielders. To date, there is no data regarding the characteristics of breast cancers that arise in NAF-yielders and non-yielders.

Methods: We examined breast cancer characteristics in NAF yielders and the non NAF yielders in an on-going case control study assessing the hormone concentrations of NAF in breast cancer cases and healthy screening controls. 299 women with recently diagnosed breast cancer were recruited from the Lynn Sage Breast Center. NAF collection was performed from the non cancer breast in the clinic, either before surgery or more than one week post-operatively. NAF yielders produced at least 2 ul of NAF. Each patient completed a detailed study questionnaire. Breast cancer characteristics were recorded on each participant.

Results: Among 299 recruited patients 130 (40%) were non NAF yielders (group A) and 169 (60%) were NAF yielders (group B). The association of breast cancer risk factors was compared between them. There were no significant differences in the tumor characteristics. The tumor size, grade, number of positive lymph nodes, and fraction of hormone receptor positive, HER2 positive, and triple negative tumors was similar in NAF-yielders and non-yielders (smallest p value 0.295, for histology, ductal versus lobular). Among the major breast cancer risk factors, the only significant differences were that NAF yielders were younger than non-yielders (50.8 vs. 53.6 years, p < 0.0001) and were more likely to have a history of post-menopausal hormone use (27% among NAF yielders and 7% among non-yielders, p < 0.0001).

Conclusions: Tumor characteristics of NAF-yielders and non-yielders are similar, suggesting that there is no qualitative difference between these two groups. The risk predictors developed in yielders can apply to non-yielders.

Prognostic classification of ipsilateral breast tumor recurrence (IBTR)

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Background: IBTR after breast conservation encompasses true recurrence (TR) and new primary cancer (NP). No clear criteria distinguish TR from NP, but there is agreement that NP tumors have better outcomes than TR. Prior studies have used distance of IBTR from index cancer (IC), time to IBTR, histological, immunohistochemical (IHC) and genetic differences, but all data are not often available. We have examined IBTR patterns with the goal of identifying the simplest, most robust determinants of outcomes following IBTR.

Methods: We reviewed records of breast cancer patients diagnosed with IBTR at the Lynn Sage Breast Center from 8/1992 to 6/2010. Data for the IBTR and IC were reviewed for histology, IHC, location, time between IC and IBTR, follow-up status, and cause of death. Parameters were scored as 1 if IBTR and IC were similar, and 0 if different (location=1 if ≤3cm; IHC=1 if hormone receptors and HER2 similar; interval=1 if ≤ 4 years). Univariate and multivariate proportional hazard models were used to determine impact on overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), distant recurrence free survival (DRFS) and local recurrence (LR). The multivariate model included significant univariate parameters.

Results: We identified 161 patients with IBTR and complete data on ≥3 parameters; post-IBTR median follow up was 25 months. Data were missing on location in 13%, histology in 9%, IHC in 26%, and time interval in 0%. In univariate analysis, short interval to IBTR significantly decreased OS (HR 2.56, p=0.04), DSS (HR 4.31, p=0.009), RFS (HR 2.25, p=0.01), DRFS (HR 2.53, p=0.02), LR (HR 2.28, p=0.02); close location of IBTR decreased OS (HR 2.68, p=0.04). Histology and receptor status had no significant impact on the outcomes. Multivariate analysis included time and location, time ≤ 4 years was shown to decrease DSS (HR 4.00, p= 0.04), RFS (HR 2.32, p=0.03) and LR (HR 2.41, p=0.03).

Conclusions: A short time interval between IC and IBTR is the most important prognostic parameter; location of IBTR within 3 cm of the IC also increases HR of subsequent events. These are the most easily available parameters when evaluating patients with IBTR, and therefore the most useful for distinction of TR versus new primary.

Relationship of recent pregnancy and cytologic atypia in the contralateral breast of patients with breast cancer

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Background: Although early parity protects against breast cancer later in life, it is a risk factor in the years following pregnancy, particularly when child-bearing is delayed. In a separate study, we have reported that these pregnancy-associated breast cancers (PABC) are more likely to be hormone receptor (HR) negative; we have previously found that random fine needle aspiration (rFNA) of the contralateral breast (CB) frequently have atypia in women with HR negative breast cancer. We now report an analysis of the cytological features of contralateral rFNA in relation to recent parity, with the goal of assessing cytological features which may be risk factors for PABC.

Methods: Women with breast cancer undergoing surgery between 2006 and 2008 were enrolled in a prospective study of rFNA of the CB. Cytological analysis was performed on all the samples, using two scoring systems, Masood and Zalles (M and Z). Linear regression analyses were performed relating each score to interval from last pregnancy, stratified for parity, and adjusted for age.

Results: Eighty-two patients had rFNA and cytologic analysis. The parous group’s (n=52) interval since last pregnancy was inversely correlated with the overall M score (p=0.034); pleomorphism and (p=0.047 and p=0.013 respectively). M score was also related to age at last pregnancy (p=0.026) as were pleomorphism and chromatin pattern (p=0.044 and 0.035 respectively). In the nulliparous group (n=30), there were no significant relationships between any of the cytological parameters or age.

Conclusions: The CB of women with recent parity display specific cytological abnormalities that are related to risk of breast cancer, particularly HR negative breast cancer. This observation affords the opportunity to further evaluate rFNA as a tool for breast cancer risk assessment following pregnancy, and to identify molecular correlates of nuclear cytological abnormalities that may serve as targets for prevention of ER negative breast cancer.

Learning sentinel node biopsy: results of a prospective randomized trial of two techniques

BACKGROUND

Evidence indicates that sentinel node (SN) biopsy can accurately predict axillary nodal status. Debate exists as to the optimal method of SN identification.

METHODS

Patients with clinical T1 or T2 tumors and negative axillae were randomized to SN localization with blue dye (B) alone (n = 50) or blue dye plus radioactivity (B+R) (n = 42). Patients undergoing needle localization (n = 47) were assigned to blue dye.

RESULTS

The SN was identified in 110 patients (79%) and contained metastases in 28. The SN predicted the axillary nodal status in 96% of cases. The SN identification rate did not differ between B (88%) or B+R (86%) but was significantly lower in patients requiring localization (64%). The time to SN identification also did not differ between B and B+R. The number of cases done by an individual surgeon was a significant predictor of SN identification. A stepwise logistic regression analysis of factors influencing the success of SN identification identified tumor location, needle localization, number of operations, and body mass index as significant predictors.

CONCLUSIONS

Our study does not identify any advantage for the use of the more expensive and complex method of SN identification using B+R compared with B alone, even for surgeons learning the techniques.

Breast conservation: predictors and treatment of local recurrence

Breast conservation therapy has become the preferred treatment for many Stage I and II breast cancers as the "Halstedian" theory of sequential spread has been replaced by the belief that breast cancer is a systemic disease and that local-regional therapy has little impact on overall survival. Local recurrence after conservation therapy is reportedly dependent upon a number of pathological, clinical, and treatment factors. This review examines the complex relationships among these factors, their ability to predict for residual disease within the breast, and its correlation with risk for local recurrence. A local recurrence does not appear to affect overall survival, and salvage therapy provides excellent local control in the majority of cases. The proper salvage therapy is evolving, with mastectomy the current standard. However, repeat wide-excision surgery may offer good local control in a select group of patients.

Postoperative radiotherapy improves survival in squamous cell carcinoma of the hypopharynx

BACKGROUND

Postoperative radiation is considered to be "standard of care" therapy for advanced, resectable squamous cell carcinoma of the head and neck. This approach has been supported by retrospective data but has not been validated in randomized clinical trials.

PATIENTS AND METHODS

The present analysis examined the clinical course of 110 patients with squamous cell cancer of the hypopharynx treated with surgery alone (n = 65) and postoperative radiotherapy alone (n = 45) between 1966 and 1990. Staging of patients was performed using the 1988 American Joint Committee on Cancer criteria. Cox regression analyses identified clinical and pathologic factors that were significant for disease-free and overall survival. Crude and adjusted cancer-specific survival rates were calculated.

RESULTS

The postoperative radiotherapy group presented with more advanced disease than the surgery alone group (stage III and IV combined, 96% versus 77%, P = 0.015). Crude 5-year cancer-specific survival probabilities were 43% for the postoperative therapy group and 27% for the surgery alone group (P = NS). Adjusted 5-year survival rates, correcting for differences in significant prognostic variables between groups, were 18% and 48%, respectively, for the surgery and postoperative radiotherapy groups (P = 0.029).

CONCLUSIONS

The addition of postoperative radiotherapy was associated with improved disease-free and adjusted overall cancer-specific survival in patients with advanced hypopharyngeal squamous cancer. The potential survival benefit of postoperative radiotherapy should be addressed in a randomized clinical trial.

Expansion and tumour specific cytokine secretion of bryostatin-activated T-cells from cryopreserved axillary lymph nodes of breast cancer patients

Current adoptive immunotherapy strategies in cancer patients require large numbers of activated T-cells and are limited by the availability of autologous tumour. We describe a novel method of T-cell activation that produced relatively rapid, high-fold expansion of stored, frozen lymphocytes obtained from the lymph nodes of 20 breast cancer patients during axillary dissection but does not require autologous tumour. In vitro exposure of thawed cells to bryostatin-1 (B), a non-tumour promoting protein kinase C activator and ionomycin (I), a calcium ionophore, at day 0 followed by culture in low dose interleukin-2 (IL-2 20 units ml-1) and restimulation again on day 10 results in 269-28,206 fold (geometric mean = 2254) expansion in cell numbers counted 17 days after initial stimulation. Analysis of cell surface markers revealed that B/I expanded human cells were predominantly T-cells (83-97%) and consisted of a mixture of CD8+ (46-74%) and CD4+ (4-30%) cells. B/I expanded cells did not lyse autologous tumour cells when tested in a 4-h 51Cr release assay, but murine studies reported previously have demonstrated specific and curative in vivo efficacy in MCA-105 tumour-bearing mice despite an inability to lyse autologous tumour in vitro. B/I expanded T-cells from five of six patients secreted the cytokines tumour necrosis factor-alpha (TNF-alpha) and interferon-gamma (IFN-gamma) in response to co-culture with autologous tumour cells but not with irrelevant tumour. These results are analogous to findings in a murine model, in which non-cytolytic B/I expanded T-cells mediated specific, curative anti-tumour effects in vivo, and lay the groundwork for a clinical trial of this novel strategy for the adoptive immunotherapy of breast cancer patients.

Activation of CD8+ murine T cells from tumor-draining lymph nodes by phorbol dibutyrate plus calcium ionophore

When lymphocytes from the lymph nodes draining the site of a progressively growing MCA-105 sarcoma are stimulated in vitro with autologous tumor and low-dose interleukin-2 (IL-2), they will grow and develop the ability to lyse autologous tumor cells in vitro; these lymphocytes can also eradicate tumor metastases in vivo. Phorbol esters and calcium ionophores activate signal transduction pathways in T cells and mimic the events triggered by antigen binding. We therefore sought to determine whether large numbers of MCA-105 tumor-specific, therapeutically active T cells could be obtained from MCA-105 draining lymph nodes (DLNs) following a brief exposure to phorbol dibutyrate (PDBu) and ionomycin (Io). DLN cells primarily stimulated with autologous tumor, followed by a secondary stimulation with PDBu-Io and cultured in 20 U/ml IL-2, demonstrated marked expansion of cell numbers during 3 weeks in culture, had moderate cytolytic activity [37% at effector:target ratio (E:T) = 80:1], and were all CD8+ T cells. In contrast, DLN cells stimulated primarily with PDBu-Io and cultured in 20 U/ml IL-2 demonstrated at least 8-10-fold greater growth than antigen-stimulated DLN cells during 3 weeks, were moderately cytolytic (31% at E:T = 80:1), and were a mixed population of CD8+ and CD4+ T lymphocytes. DLN cells that were expanded by either protocol, like cells stimulated repeatedly in vitro with tumor cells, could eliminate MCA-105 pulmonary metastases when given with IL-2 in an adoptive immunotherapy model. DLN cells stimulated primarily with PDBu-Io completely eradicated MCA-105 metastases but had no in vivo antitumor activity against the syngeneic B16 melanoma or MCA-203 sarcoma.(ABSTRACT TRUNCATED AT 250 WORDS)

Bryostatin 1-activated T cells can traffic and mediate tumor regression

Adoptive immunotherapy in humans may be limited by the lack of autologous tumor cells to activate and expand tumor-specific T cells. Pharmacologic manipulation of protein kinase C (PKC) and intracellular calcium may substitute for tumor antigen and stimulate T cells for adoptive immunotherapy. In the present study, we evaluated the ability of the PKC activator Bryostatin 1 (B) plus the calcium ionophore ionomycin (I) to activate lymphocytes obtained from popliteal lymph nodes (DLN) draining an MCA-105 footpad tumor. The adoptive transfer of B/I-stimulated DLN cells eradicated MCA-105 pulmonary metastases. These lymphocytes do not require concomitant IL-2 administration to mediate regression of lung metastases. Three days after intrasplenic injection of tumor cells and splenectomy, mice were given iv injections of B/I-stimulated DLN cells. Adoptive immunotherapy with these cells induced regression of established liver metastases. In an intradermal tumor model, the adoptive transfer of B/I-stimulated MCA-105 DLN cells cured mice of MCA-105 intradermal (id) tumors, but did not induce regression of MCA-206 tumors. Mice cured of MCA-105 id tumors were protected against MCA-105, but not MCA-203, tumor challenge in the footpad 7 weeks after adoptive immunotherapy.

Activation and growth of murine tumor-specific T-cells which have in vivo activity with bryostatin 1

We examined the ability of bryostatin 1 (Bryo), a novel protein kinase C activator, plus ionomycin (Io), a calcium ionophore, to activate T-cells with specific antitumor activity. Lymphocytes from the draining lymph nodes (DLN) of MCA-105 tumor-bearing host mice were stimulated with Bryo/Io, either fresh or after in vitro stimulation with autologous tumor, and then were incubated in interleukin-2 at 20 units/ml. Lymphocytes sensitized with tumor cells in vitro and then stimulated with Bryo/Io exhibited significant expansion (12-fold) after a total of 3 weeks in culture and moderate cytolytic activity (40% at an effector:tumor cell ratio of (80:1) and were exclusively CD8+ T-cells. DLN cells activated immediately with Bryo/Io, without tumor antigen sensitization in vitro, displayed marked growth (130-fold expansion) over 3 weeks in culture, had weak cytolytic activity (8% at an effector:tumor ratio of 80:1), and were a mixed population of CD8+ and CD4+ cells. Despite the differences in phenotypes and in cytotoxicity, both groups of DLN cells were highly effective in vivo against MCA-105 pulmonary metastases. Bryo/Io-activated DLN cells from MCA-105 tumor-bearing hosts had no therapeutic efficacy against B16 melanoma or MCA-203 sarcoma metastases. Lymph node cells from normal mice and non-draining lymph node cells from tumor-bearing hosts could be expanded with Bryo/Io to a degree similar to that of DLN cells but had no antitumor activity. Phenotypic analyses and in vitro and in vivo depletion studies demonstrate that CD8+ cells mediated tumor regression.

Enhancement of cytotoxic T lymphocyte growth from spleens of P815-tumor-bearing host mice with mafosfamide

Mafosfamide (Mafo) is an analog of cyclophosphamide that does not require hepatic activation and therefore has in vitro activity. The present study was conducted to determine the effects of in vitro treatment with Mafo on the generation and growth of cytotoxic T lymphocytes (CTL) from tumor-bearing host mice (TBH). In contrast to early (day-11) TBH splenocytes, splenocytes from late (days 18-20) P815 TBH mice suppress the in vitro generation of CTL. Treatment of late TBH splenocytes in vitro with 5-15 microM Mafo resulted in a reduced ability of these cells to suppress in vitro CTL generation. Treatment of late TBH splenocytes with 10 microM Mafo also inhibited their ability to suppress adoptive immunotherapy of intradermal tumors with immune splenocytes. These doses of Mafo were selectively toxic to the suppressive effects of late TBH splenocytes, since treatment of early TBH splenocytes with 1-10 microM Mafo did not significantly inhibit CTL generation. Spleen cells from early (days 10-12) TBH mice, carried in long-term in vitro sensitization cultures in the presence of tumor cells and 20 U/ml human recombinant interleukin-2, did not increase in cell number over time. However, when pretreated with 3 microM Mafo, this population of tumor-sensitized lymphocytes demonstrated 450-fold growth over 6 weeks as compared to the static cell numbers for the untreated controls. High levels of tumor-specific cytolytic activity were maintained in these expanded cells. These results suggest that Mafo pretreatment markedly and selectively inhibits suppressor cells that limit long-term expansion of splenic CTL in culture and inhibit adoptive immunotherapy of solid tumors.

Diagnosis and management of sacrococcygeal chordoma

Chordoma is a rare, slow-growing but locally aggressive malignant tumor derived from the primitive notochord and located along the axial skeleton. Between 1973 and 1991, of 15 patients with chordomas treated at the Medical College of Virginia, eight originated in the sacrococcygeal area. There was a median one year interval between the onset of symptoms and diagnosis (range of four months to six years) for this latter group. Two patients had undergone coccygectomies and one patient a lumbar discectomy prior to establishing the correct diagnosis of sacral chordoma. Seven patients underwent resection and one refused therapy. The four patients who had an initial wide radical resection had a longer disease-free survival than the three who underwent local excision. Three of four patients had metastatic disease at the time of death. Early diagnosis and aggressive initial surgical resection are necessary for long-term survival.

Successful long-term cryopreservation and transplantation of human fetal pancreas

To obtain sufficient quantities of human fetal pancreatic tissue (HFP) for transplantation, long-term storage of the tissue must be achieved. The functional viability of HFP after cryopreservation by stepwise addition of dimethyl sulfoxide was determined. Human fetal pancreas explants (1-2 mm3; gestational age 16-21 wk) were prepared and slowly cooled (0.25 degrees C/min) to -40 degrees C before placement in liquid nitrogen. After rapid thaw (37 degrees C) and overnight culture, insulin release in response to high glucose and theophylline challenge determined in vitro functional viability. No difference was found between the responses of fresh and cryopreserved tissue (fresh 29.2 +/- 3.0 ng/mg tissue, cryopreserved 29.9 +/- 3.3 ng/mg tissue; P greater than .1). Diabetic BALB/c nu/nu mice transplanted with cryopreserved HFP returned to normoglycemia in 11 +/- 2 wk (range 8-15 wk). Oral glucose tolerance tests indicated in vivo serum glucose control equivalent to or better than that of nondiabetic control mice (peak serum glucose of nondiabetic mice 164 +/- 66 mg/dl, of cryopreserved grafted mice 180 +/- 67 mg/dl; P greater than .8). In vitro insulin release of cryopreserved grafted tissue demonstrated that the tissue had differentiated and matured and was now capable of responding to high-glucose challenge (39.3 +/- 11.5 ng insulin released/mg tissue). The results described herein are the first demonstration that cryopreserved HFP maintains the in vivo capacity to differentiate and mature and the capacity to reverse diabetes in an animal system.