Abstract P5-11-13: Tamoxifen and Ovarian Function

Background: to study and compare ovarian function (clinical and biological data) among premenopausal breast cancer patients receiving tamoxifen alone (group I) or tamoxifen following chemotherapy (group II), because some studies suggest that amenorrhea is an insufficient parameter to define menopausal status.

Material and methods: between 1999 and 2003, 138 premenopausal patients, treated for early breast cancer, were included: 68 patients in the group of tamoxifen alone and 70 patients in de group of tamoxifen administered after chemotherapy (6 cycles of FEC 100 on day 1 every 3 weeks -5 fluorouracil 500 mg/m2, epirubicin 100 mg/m2 and cyclophosphamide 500 mg/m2- or 4 cycles of EC on day 1 every 3 weeks -epiadriamycine 75 mg/m2, cyclophosphamide 500 mg/m2-). All patients had a confirmed premenopausal status (biological data) at the entry of the study. The median age in group I was 44.5 (36 to 48) and 42 in group II (35 to 47.5). In group I, all were stage I and in group II, 34 were stage I and 36 were stage II. They were followed prospectively every 3 months for 3 years: date about menses, physical examination and blood tests (LH, FSH, 17-bêta-estradiol). Vaginal echography was added every 6 months. After 3 years, prospective evaluation was closed. Retrospective evaluation of all data was performed in 2009.

Results: three patients were out of study in the group I and 2 were out of study in the group II. According to clinical data, patients were devided in 4 subgroups:

a: regular menses (≥10 cycles/year) b: spaniomenorrhea (5 to 9 cycles/year) c: severe spaniomenorrhea (1 to 4 cycles/year) d: complete amenorrhea.

The number of patients in each subgroup is respectively:

- For group I (65 patients): 3 (4%), 19 (29%), 38 (58%) and 5 (8%).

- For group II (68 patients): 2 (3%), 21 (30%), 38 (55%) and 7 (10%). The most interesting parameter to be studied wass the estradiol levels.

Median values of estrogen levels

For patients of subgroup a, tamoxifen mimicked an ovulatory cycle such as observed in patients receiving citrate of clomifen. For patients of subgroup b, the variations corresponded to nearly a normal ovulatory cycle. For patients of subgroups c and d, tamoxifen induced low levels of estradiol, LH and FSH, and very few variations. Estrogen levels did not to seem have an impact on disease free survival rate after 3 years of follow-up (100% in group I and 98.6% in group II and after 5 years (98.5% and 97%). In the two groups I and II, estrogen levels from patients of subgroups a and b were significantly higher than in subgroups c and d (p < 0.001). Conclusion: amenorrhea is an insufficient parameter to define menopausal status of patients receiving tamoxifen. Low estradiol level must be coupled to other biological parameters to characterize endocrine status. These data are very important in the choice of endocrine therapy.

[Contribution of MRI for monitoring response to neoadjuvant chemotherapy in the management of breast cancer]

In the management of breast neoplasms, two breast MR examinations are performed, one before initiation of neoadjuvant chemotherapy (NAC) and one at the end. However, a third MR exam may be performed between two courses of chemotherapy in order to assess tumor response to treatment. The assessment criterion currently used is measurement of tumor diameter according to RECIST (Response Evaluation Criteria In Solid Tumors) and WHO. But according to the preliminary results of the American College of Radiology Imaging Network protocol, using measurement of tumor volume as a reference may be valuable. Larger series are therefore necessary to estimate the value of diffusion MR, spectroscopy and diffusion studies.

[US and dense breasts: where do we stand?]

The use of ultrasonography in dense breast remains a controversial topic. It is acknowledged that ultrasound as an adjunct to mammography increases the detection rate of breast cancers. However, the main limitation of US, in addition to its operator dependent nature, is its low specificity, leading to a high rate of false positive results. Several techniques can be used to improve the performance of US and cost/effectiveness ratio, such as Doppler imaging, harmonic imaging, spatial and frequency compound imaging, all of which are routinely available, and elastosonography, contrast US and 3D US which are still in development.

[Contribution of sonoelastography to the characterization of breast lesions]

We evaluate the performances of sonoelastography in the characterization of breast nodules with histologic correlation. Elastosonography was performed immediately after mode B sonography in 59 patients (65 nodules) by two radiologists, independently. All sequences of elastosonography were recorded. An intra and inter -observers correlation was calculated. Each nodule was classified with BI-RADS lexicon and with Ueno elastography classification. The scores 1-3 were considered as benign and 4-5 as malignant. A cytologic/histologic diagnosis was available for all nodules. At histology, 16 nodules were malignant and 49 nodules were benign. The intra and inter-observer correlations of elastosonography were excellent. The sensitivity, specificity, PPV, NPV of sonoelastography were 87.5%, 98%, 93.3%, 96%, respectively comparing with 100%, 93.9%, 84%, 100% of Mode B sonography. Thus, 95% (36/38 nodules) of BI-RADS 3 nodules were reclassified score 2 or 1 with elastosonography, decreasing the rates of fine needle aspiration and short-term follow-up. Elastosonography is a simple, rapid and complementary method to mode B sonography that can improve the specificity in the characterization of breast nodules and the management of BI-RADS 3 nodules, leading to a decrease of false-positive and short term follow-up rates.

Papillomatose juvénile mammaire

The authors report a patient with juvenile papillomatosis of the breast presenting with a palpable mass and illustrate the correlation between mammographic, sonographic and pathologic features.

LH-RH agonists offer very good protection against the adverse gynaecological effects induced by tamoxifen

This study was initiated to evaluate the efficacy of luteinizing hormone-releasing hormone (LH-RH) agonists in protecting premenopausal patients against the adverse gynaecological effects induced by tamoxifen. Between January 1998 and January 2000, 85 premenopausal breast cancer patients were included in this prospective study. All were to receive LH-RH agonists and tamoxifen for a minimum of two years. All patients underwent a pretreatment gynaecological evaluation and annual follow-up. Bone density was also measured at the start of treatment and then after 2, 3 and 4 years. Pretreatment evaluation revealed 2 polyps. At one and two years of follow-up, no abnormal symptoms were noted and echographic findings were normal. At three years of follow-up, a polyp associated with adnexal masses was discovered. Histology revealed ovarian and endometrial metastases of infiltrating lobular breast carcinoma. Bone density evaluation after 2, 3 and 4 years of treatment showed no significant bone loss. LH-RH agonists offer safe protection against the gynaecological side-effects of tamoxifen in premenopausal breast cancer patients.