1
|
Sahoo S, Krings G, Chen YY, Carter JM, Chen B, Guo H, Hibshoosh H, Reisenbichler E, Fan F, Wei S, Khazai L, Balassanian R, Klein ME, Shad S, Venters SJ, Borowsky AD, Symmans WF, Ocal IT. Standardizing Pathologic Evaluation of Breast Carcinoma After Neoadjuvant Chemotherapy. Arch Pathol Lab Med 2022; 147:591-603. [PMID: 35976643 DOI: 10.5858/arpa.2022-0021-ep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Neoadjuvant systemic therapy refers to the use of systemic agent(s) for malignancy prior to surgical treatment and has recently emerged as an option for most breast cancer patients eligible for adjuvant systemic therapy. Consequently, treated breast carcinomas have become routine specimens in pathology practices. A standard protocol has not yet been universally adopted for the evaluation and reporting of these specimens. The American Joint Committee on Cancer staging system recognizes the challenges in staging breast carcinomas after neoadjuvant treatment and provides important data points but does not currently provide detailed guidance in estimating the residual tumor burden in the breast and lymph nodes. The Residual Cancer Burden system is the only Web-based system that quantifies treatment response as a continuous variable using residual tumor burden in the breast and the lymph nodes. OBJECTIVE.— To provide clarifications and guidance for evaluation and reporting of postneoadjuvant breast specimens, discuss issues with the current staging and reporting systems, and provide specific suggestions for future modifications to the American Joint Committee on Cancer system and the Residual Cancer Burden calculator. DATA SOURCES.— English-language literature on the subject and the data from the I-SPY 2, a multicenter, adaptive randomization phase 2 neoadjuvant platform trial for early-stage, high-risk breast cancer patients. CONCLUSIONS.— This article highlights challenges in the pathologic evaluation and reporting of treated breast carcinomas and provides recommendations and clarifications for pathologists and clinicians. It also provides specific recommendations for staging and discusses future directions.
Collapse
Affiliation(s)
- Sunati Sahoo
- From the Department of Pathology, UTSW Medical Center, Dallas, Texas (Sahoo)
| | - Gregor Krings
- From the Department of Pathology (Krings, Y.-Y. Chen, Balassanian), University of California, San Francisco
| | - Yunn-Yi Chen
- From the Department of Pathology (Krings, Y.-Y. Chen, Balassanian), University of California, San Francisco
| | - Jodi M Carter
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota (Carter, B. Chen)
| | - Beiyun Chen
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota (Carter, B. Chen)
| | - Hua Guo
- From the Department of Pathology and Cell Biology, Columbia University, New York, New York (Guo, Hibshoosh)
| | - Hanina Hibshoosh
- From the Department of Pathology and Cell Biology, Columbia University, New York, New York (Guo, Hibshoosh)
| | - Emily Reisenbichler
- From the Department of Pathology, Saint Louis University School of Medicine, St Louis, Missouri (Reisenbichler)
| | - Fang Fan
- From the Department of Pathology, City of Hope Comprehensive Cancer Center, Duarte, California (Fan)
| | - Shi Wei
- From the Department of Pathology and Laboratory Medicine, University of Kansas School of Medicine, Lawrence (Wei).,From the Department of Pathology, University of Birmingham, Birmingham, Alabama (Wei)
| | - Laila Khazai
- From the Department of Pathology, University of Texas MD Anderson Cancer Center, Houston (Khazai, Symmans)
| | - Ronald Balassanian
- From the Department of Pathology (Krings, Y.-Y. Chen, Balassanian), University of California, San Francisco
| | - Molly E Klein
- From the Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis (Klein)
| | - Sonal Shad
- From the Department of Laboratory Medicine (Shad, Venters), University of California, San Francisco
| | - Sara J Venters
- From the Department of Laboratory Medicine (Shad, Venters), University of California, San Francisco
| | - Alexander D Borowsky
- From the Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento (Borowsky)
| | - W Fraser Symmans
- From the Department of Pathology, University of Texas MD Anderson Cancer Center, Houston (Khazai, Symmans)
| | - I Tolgay Ocal
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona (Ocal)
| |
Collapse
|
2
|
Yau C, Osdoit M, van der Noordaa M, Shad S, Wei J, de Croze D, Hamy AS, Laé M, Reyal F, Sonke GS, Steenbruggen TG, van Seijen M, Wesseling J, Martín M, Del Monte-Millán M, López-Tarruella S, Boughey JC, Goetz MP, Hoskin T, Gould R, Valero V, Edge SB, Abraham JE, Bartlett JMS, Caldas C, Dunn J, Earl H, Hayward L, Hiller L, Provenzano E, Sammut SJ, Thomas JS, Cameron D, Graham A, Hall P, Mackintosh L, Fan F, Godwin AK, Schwensen K, Sharma P, DeMichele AM, Cole K, Pusztai L, Kim MO, van 't Veer LJ, Esserman LJ, Symmans WF. Residual cancer burden after neoadjuvant chemotherapy and long-term survival outcomes in breast cancer: a multicentre pooled analysis of 5161 patients. Lancet Oncol 2022; 23:149-160. [PMID: 34902335 PMCID: PMC9455620 DOI: 10.1016/s1470-2045(21)00589-1] [Citation(s) in RCA: 145] [Impact Index Per Article: 72.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Previous studies have independently validated the prognostic relevance of residual cancer burden (RCB) after neoadjuvant chemotherapy. We used results from several independent cohorts in a pooled patient-level analysis to evaluate the relationship of RCB with long-term prognosis across different phenotypic subtypes of breast cancer, to assess generalisability in a broad range of practice settings. METHODS In this pooled analysis, 12 institutes and trials in Europe and the USA were identified by personal communications with site investigators. We obtained participant-level RCB results, and data on clinical and pathological stage, tumour subtype and grade, and treatment and follow-up in November, 2019, from patients (aged ≥18 years) with primary stage I-III breast cancer treated with neoadjuvant chemotherapy followed by surgery. We assessed the association between the continuous RCB score and the primary study outcome, event-free survival, using mixed-effects Cox models with the incorporation of random RCB and cohort effects to account for between-study heterogeneity, and stratification to account for differences in baseline hazard across cancer subtypes defined by hormone receptor status and HER2 status. The association was further evaluated within each breast cancer subtype in multivariable analyses incorporating random RCB and cohort effects and adjustments for age and pretreatment clinical T category, nodal status, and tumour grade. Kaplan-Meier estimates of event-free survival at 3, 5, and 10 years were computed for each RCB class within each subtype. FINDINGS We analysed participant-level data from 5161 patients treated with neoadjuvant chemotherapy between Sept 12, 1994, and Feb 11, 2019. Median age was 49 years (IQR 20-80). 1164 event-free survival events occurred during follow-up (median follow-up 56 months [IQR 0-186]). RCB score was prognostic within each breast cancer subtype, with higher RCB score significantly associated with worse event-free survival. The univariable hazard ratio (HR) associated with one unit increase in RCB ranged from 1·55 (95% CI 1·41-1·71) for hormone receptor-positive, HER2-negative patients to 2·16 (1·79-2·61) for the hormone receptor-negative, HER2-positive group (with or without HER2-targeted therapy; p<0·0001 for all subtypes). RCB score remained prognostic for event-free survival in multivariable models adjusted for age, grade, T category, and nodal status at baseline: the adjusted HR ranged from 1·52 (1·36-1·69) in the hormone receptor-positive, HER2-negative group to 2·09 (1·73-2·53) in the hormone receptor-negative, HER2-positive group (p<0·0001 for all subtypes). INTERPRETATION RCB score and class were independently prognostic in all subtypes of breast cancer, and generalisable to multiple practice settings. Although variability in hormone receptor subtype definitions and treatment across patients are likely to affect prognostic performance, the association we observed between RCB and a patient's residual risk suggests that prospective evaluation of RCB could be considered to become part of standard pathology reporting after neoadjuvant therapy. FUNDING National Cancer Institute at the US National Institutes of Health.
Collapse
Affiliation(s)
- Christina Yau
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
| | - Marie Osdoit
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA; Department of Surgery, Institut Curie, Paris, France
| | | | - Sonal Shad
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Jane Wei
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Diane de Croze
- Department of Tumor Biology, Institut Curie, Paris, France
| | | | - Marick Laé
- Department of Tumor Biology, Institut Curie, Paris, France; Department of Pathology, Université de Rouen Normandie, Rouen, France
| | - Fabien Reyal
- Department of Surgery, Institut Curie, Paris, France
| | - Gabe S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Tessa G Steenbruggen
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Maartje van Seijen
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Jelle Wesseling
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Miguel Martín
- Department of Medical Oncology, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Maria Del Monte-Millán
- Department of Medical Oncology, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Sara López-Tarruella
- Department of Medical Oncology, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | | | - Tanya Hoskin
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Rebekah Gould
- Department of Pathology and Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vicente Valero
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stephen B Edge
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Jean E Abraham
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - John M S Bartlett
- Diagnostic Development Program, Ontario Institute for Cancer Research, Toronto, Canada; Deanery of Molecular, Genetic and Population Health Sciences, Edinburgh Cancer Research Centre, Edinburgh, UK; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Carlos Caldas
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Janet Dunn
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Helena Earl
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Larry Hayward
- Department of Oncology, Western General Hospital, Edinburgh, UK
| | - Louise Hiller
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Elena Provenzano
- Department of Histopathology, University of Cambridge, Cambridge, UK
| | | | - Jeremy S Thomas
- Department of Pathology, Western General Hospital, Edinburgh, UK
| | - David Cameron
- Department of Oncology, Western General Hospital, Edinburgh, UK
| | - Ashley Graham
- Department of Pathology, Western General Hospital, Edinburgh, UK
| | - Peter Hall
- Department of Oncology, Western General Hospital, Edinburgh, UK
| | - Lorna Mackintosh
- Department of Pathology, Western General Hospital, Edinburgh, UK
| | - Fang Fan
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Andrew K Godwin
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Kelsey Schwensen
- Department of Medical Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Priyanka Sharma
- Department of Medical Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Angela M DeMichele
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kimberly Cole
- Department of Pathology, Yale University, New Haven, CT, USA
| | - Lajos Pusztai
- Department of Medical Oncology, Yale University, New Haven, CT, USA
| | - Mi-Ok Kim
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Laura J van 't Veer
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Laura J Esserman
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - W Fraser Symmans
- Department of Pathology and Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
3
|
Symmans WF, Yau C, Chen YY, Balassanian R, Klein ME, Pusztai L, Nanda R, Parker BA, Datnow B, Krings G, Wei S, Feldman MD, Duan X, Chen B, Sattar H, Khazai L, Zeck JC, Sams S, Mhawech-Fauceglia P, Rendi M, Sahoo S, Ocal IT, Fan F, LeBeau LG, Vinh T, Troxell ML, Chien AJ, Wallace AM, Forero-Torres A, Ellis E, Albain KS, Murthy RK, Boughey JC, Liu MC, Haley BB, Elias AD, Clark AS, Kemmer K, Isaacs C, Lang JE, Han HS, Edmiston K, Viscusi RK, Northfelt DW, Khan QJ, Leyland-Jones B, Venters SJ, Shad S, Matthews JB, Asare SM, Buxton M, Asare AL, Rugo HS, Schwab RB, Helsten T, Hylton NM, van 't Veer L, Perlmutter J, DeMichele AM, Yee D, Berry DA, Esserman LJ. Assessment of Residual Cancer Burden and Event-Free Survival in Neoadjuvant Treatment for High-risk Breast Cancer: An Analysis of Data From the I-SPY2 Randomized Clinical Trial. JAMA Oncol 2021; 7:1654-1663. [PMID: 34529000 DOI: 10.1001/jamaoncol.2021.3690] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Residual cancer burden (RCB) distributions may improve the interpretation of efficacy in neoadjuvant breast cancer trials. Objective To compare RCB distributions between randomized control and investigational treatments within subtypes of breast cancer and explore the relationship with survival. Design, Setting, and Participants The I-SPY2 is a multicenter, platform adaptive, randomized clinical trial in the US that compares, by subtype, investigational agents in combination with chemotherapy vs chemotherapy alone in adult women with stage 2/3 breast cancer at high risk of early recurrence. Investigational treatments graduated in a prespecified subtype if there was 85% or greater predicted probability of higher rate of pathologic complete response (pCR) in a confirmatory, 300-patient, 1:1 randomized, neoadjuvant trial in that subtype. Evaluation of a secondary end point was reported from the 10 investigational agents tested in the I-SPY2 trial from March 200 through 2016, and analyzed as of September 9, 2020. The analysis plan included modeling of RCB within subtypes defined by hormone receptor (HR) and ERBB2 status and compared control treatments with investigational treatments that graduated and those that did not graduate. Interventions Neoadjuvant paclitaxel plus/minus 1 of several investigational agents for 12 weeks, then 12 weeks of cyclophosphamide/doxorubicin chemotherapy followed by surgery. Main Outcomes and Measures Residual cancer burden (pathological measure of residual disease) and event-free survival (EFS). Results A total of 938 women (mean [SD] age, 49 [11] years; 66 [7%] Asian, 103 [11%] Black, and 750 [80%] White individuals) from the first 10 investigational agents were included, with a median follow-up of 52 months (IQR, 29 months). Event-free survival worsened significantly per unit of RCB in every subtype of breast cancer (HR-positive/ERBB2-negative: hazard ratio [HZR], 1.75; 95% CI, 1.45-2.16; HR-positive/ERBB2-positive: HZR, 1.55; 95% CI, 1.18-2.05; HR-negative/ERBB2-positive: HZR, 2.39; 95% CI, 1.64-3.49; HR-negative/ERBB2-negative: HZR, 1.99; 95% CI, 1.71-2.31). Prognostic information from RCB was similar from treatments that graduated (HZR, 2.00; 95% CI, 1.57-2.55; 254 [27%]), did not graduate (HZR, 1.87; 95% CI, 1.61-2.17; 486 [52%]), or were control (HZR, 1.79; 95% CI, 1.42-2.26; 198 [21%]). Investigational treatments significantly lowered RCB in HR-negative/ERBB2-negative (graduated and nongraduated treatments) and ERBB2-positive subtypes (graduated treatments), with improved EFS (HZR, 0.61; 95% CI, 0.41-0.93) in the exploratory analysis. Conclusions and Relevance In this randomized clinical trial, the prognostic significance of RCB was consistent regardless of subtype and treatment. Effective neoadjuvant treatments shifted the distribution of RCB in addition to increasing pCR rate and appeared to improve EFS. Using a standardized quantitative method to measure response advances the interpretation of efficacy. Trial Registration ClinicalTrials.gov Identifier: NCT01042379.
Collapse
Affiliation(s)
- W Fraser Symmans
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston
| | - Christina Yau
- Department of Surgery, University of California, San Francisco
| | - Yunn-Yi Chen
- Department of Pathology, University of California, San Francisco
| | - Ron Balassanian
- Department of Pathology, University of California, San Francisco
| | - Molly E Klein
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis
| | - Lajos Pusztai
- Department of Medicine, Medical Oncology, Yale University, New Haven, Connecticut
| | - Rita Nanda
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Barbara A Parker
- Division of Hematology-Oncology, Department of Medicine, University of California, San Diego, La Jolla
| | - Brian Datnow
- Department of Pathology, University of California, San Diego, La Jolla
| | - Gregor Krings
- Department of Pathology, University of California, San Francisco
| | - Shi Wei
- Department of Anatomic Pathology, University of Alabama at Birmingham
| | - Michael D Feldman
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia
| | - Xiuzhen Duan
- Department of Pathology, Loyola University, Chicago, Illinois
| | - Beiyun Chen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Husain Sattar
- Department of Pathology, University of Chicago, Chicago, Illinois
| | - Laila Khazai
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida
| | - Jay C Zeck
- Department of Pathology, Georgetown University, Washington, DC
| | - Sharon Sams
- Department of Pathology, University of Colorado Anschutz Medical Center, Aurora
| | | | - Mara Rendi
- Department of Anatomic Pathology, University of Washington, Seattle
| | - Sunati Sahoo
- Department of Pathology, University of Texas Southwestern, Dallas
| | - Idris Tolgay Ocal
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona
| | - Fang Fan
- Department of Pathology, University of Kansas Medical Center, Kansas City
| | | | - Tuyethoa Vinh
- Department of Pathology, Inova Health System, Fairfax, Virginia
| | - Megan L Troxell
- Department of Pathology, Oregon Health and Science University, Portland
| | - A Jo Chien
- Division of Hematology-Oncology, Department of Medicine, University of California, San Francisco
| | - Anne M Wallace
- Department of Surgery, University of California, San Diego, La Jolla
| | - Andres Forero-Torres
- Division of Hematology-Oncology, Department of Medicine, University of Alabama at Birmingham
| | - Erin Ellis
- Medical Oncology, Swedish Cancer Institute, Seattle, Washington
| | - Kathy S Albain
- Division of Hematology-Oncology, Department of Medicine, Loyola University Chicago Stritch School of Medicine, Chicago, Illinois
| | - Rashmi K Murthy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Judy C Boughey
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Minetta C Liu
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Barbara B Haley
- Division of Hematology-Oncology, Department of Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Anthony D Elias
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Center, Aurora
| | - Amy S Clark
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Kathleen Kemmer
- Division of Hematology-Oncology, Department of Medicine, Oregon Health & Science University, Portland
| | - Claudine Isaacs
- Division of Hematology-Oncology, Department of Medicine, Georgetown University, Washington, DC
| | - Julie E Lang
- Department of Surgery, University of Southern California, Los Angeles
| | - Hyo S Han
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Kirsten Edmiston
- Department of Surgery, Inova Schar Cancer Institute, Fairfax, Virginia
| | - Rebecca K Viscusi
- Department of Surgery, University of Arizona Health Sciences, Tucson, Arizona
| | - Donald W Northfelt
- Department of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, Arizona
| | - Qamar J Khan
- Division of Oncology, Department of Medicine, University of Kansas, Kansas City
| | | | - Sara J Venters
- Department of Laboratory Medicine, University of California, San Francisco
| | - Sonal Shad
- Department of Surgery, University of California, San Francisco
| | | | - Smita M Asare
- Quantum Leap Healthcare Collaborative, San Francisco, California
| | | | - Adam L Asare
- Quantum Leap Healthcare Collaborative, San Francisco, California
| | - Hope S Rugo
- Division of Hematology-Oncology, Department of Medicine, University of California, San Francisco
| | - Richard B Schwab
- Division of Hematology-Oncology, Department of Medicine, University of California, San Diego, La Jolla
| | - Teresa Helsten
- Division of Hematology-Oncology, Department of Medicine, University of California, San Diego, La Jolla
| | - Nola M Hylton
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Laura van 't Veer
- Department of Laboratory Medicine, University of California, San Francisco
| | | | - Angela M DeMichele
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Douglas Yee
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis
| | | | | |
Collapse
|
4
|
Du L, Yau C, Brown-Swigart L, Gould R, Krings G, Hirst GL, Bedrosian I, Layman RM, Carter JM, Klein M, Venters S, Shad S, van der Noordaa M, Chien AJ, Haddad T, Isaacs C, Pusztai L, Albain K, Nanda R, Tripathy D, Liu MC, Boughey J, Schwab R, Hylton N, DeMichele A, Perlmutter J, Yee D, Berry D, Van't Veer L, Valero V, Esserman LJ, Symmans WF. Predicted sensitivity to endocrine therapy for stage II-III hormone receptor-positive and HER2-negative (HR+/HER2-) breast cancer before chemo-endocrine therapy. Ann Oncol 2021; 32:642-651. [PMID: 33617937 DOI: 10.1016/j.annonc.2021.02.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 02/07/2021] [Accepted: 02/13/2021] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND We proposed that a test for sensitivity to the adjuvant endocrine therapy component of treatment for patients with stage II-III breast cancer (SET2,3) should measure transcription related to estrogen and progesterone receptors (SETER/PR index) adjusted for a baseline prognostic index (BPI) combining clinical tumor and nodal stage with molecular subtype by RNA4 (ESR1, PGR, ERBB2, and AURKA). PATIENTS AND METHODS Patients with clinically high-risk, hormone receptor-positive (HR+), human epidermal growth factor receptor 2 (HER2)-negative (HR+/HER2-) breast cancer received neoadjuvant taxane-anthracycline chemotherapy, surgery with measurement of residual cancer burden (RCB), and then adjuvant endocrine therapy. SET2,3 was measured from pre-treatment tumor biopsies, evaluated first in an MD Anderson Cancer Center (MDACC) cohort (n = 307, 11 years' follow-up, U133A microarrays), cut point was determined, and then independent, blinded evaluation was carried out in the I-SPY2 trial (n = 268, high-risk MammaPrint result, 3.8 years' follow-up, Agilent-44K microarrays, NCI Clinical Trials ID: NCT01042379). Primary outcome measure was distant relapse-free survival. Multivariate Cox regression models tested prognostic independence of SET2,3 relative to RCB and other molecular prognostic signatures, and whether other prognostic signatures could substitute for SETER/PR or RNA4 components of SET2,3. RESULTS SET2,3 added independent prognostic information to RCB in the MDACC cohort: SET2,3 [hazard ratio (HR) 0.23, P = 0.004] and RCB (HR 1.77, P < 0.001); and the I-SPY2 trial: SET2,3 (HR 0.27, P = 0.031) and RCB (HR 1.68, P = 0.008). SET2,3 provided similar prognostic information irrespective of whether RCB-II or RCB-III after chemotherapy, and in both luminal subtypes. Conversely, RCB was most strongly prognostic in cancers with low SET2,3 status (MDACC P < 0.001, I-SPY2 P < 0.001). Other molecular signatures were not independently prognostic; they could effectively substitute for RNA4 subtype within the BPI component of SET2,3, but they could not effectively substitute for SETER/PR index. CONCLUSIONS SET2,3 added independent prognostic information to chemotherapy response (RCB) and baseline prognostic score or subtype. Approximately 40% of patients with clinically high-risk HR+/HER2- disease had high SET2,3 and could be considered for clinical trials of neoadjuvant endocrine-based treatment.
Collapse
Affiliation(s)
- L Du
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - C Yau
- Department of Surgery, University of California, San Francisco, USA
| | - L Brown-Swigart
- Department of Pathology, University of California, San Francisco, USA
| | - R Gould
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - G Krings
- Department of Pathology, University of California, San Francisco, USA
| | - G L Hirst
- Department of Surgery, University of California, San Francisco, USA
| | - I Bedrosian
- Department of Breast Surgery, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - R M Layman
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - J M Carter
- Department of Pathology, Mayo Clinic, Rochester, USA
| | - M Klein
- Department of Pathology, University of Minnesota, Minneapolis, USA
| | - S Venters
- Department of Surgery, University of California, San Francisco, USA
| | - S Shad
- Department of Surgery, University of California, San Francisco, USA
| | | | - A J Chien
- Department of Medicine, University of California, San Francisco, USA
| | - T Haddad
- Department of Medicine, Mayo Clinic, Rochester, USA
| | - C Isaacs
- Department of Medicine, Georgetown University, Washington, USA
| | - L Pusztai
- Department of Medicine, Yale University School of Medicine, New Haven, USA
| | - K Albain
- Department of Medicine, Loyola University, Chicago, USA
| | - R Nanda
- Department of Medicine, University of Chicago, Chicago, USA
| | - D Tripathy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - M C Liu
- Department of Medicine, Mayo Clinic, Rochester, USA
| | - J Boughey
- Department of Surgery, Mayo Clinic, Rochester, USA
| | - R Schwab
- Department of Medicine, University of California, San Diego, USA
| | - N Hylton
- Department of Radiology, University of California, San Francisco, USA
| | - A DeMichele
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, San Philadelphia, USA
| | | | - D Yee
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - D Berry
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - L Van't Veer
- Department of Pathology, University of California, San Francisco, USA
| | - V Valero
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - L J Esserman
- Department of Surgery, University of California, San Francisco, USA
| | - W F Symmans
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Pathology, The University of Texas MD Anderson Cancer Center, San Francisco, USA.
| |
Collapse
|
5
|
Venters SJ, Li W, Wolf DM, Carter JM, Klein ME, Singh K, Rabe K, Ocal IT, Newitt D, Yau C, Onishi N, Gibbs J, Sahoo S, Harada S, Khazai L, Harigopal M, Borowsky AD, Krings G, Balassanian R, Chen YY, Cole K, Shad S, LeStage B, Delson A, Finestone S, Brown-Swigart L, Esserman L, van ‘t Veer L, Symmans WF, Hylton NM. Abstract PS4-10: Serial MRI and pathology combined to select candidates for therapy de-escalation in the I-SPY 2 TRIAL. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-ps4-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: The I-SPY 2 TRIAL, open to patients with locally advanced, molecular high-risk breast cancer, aims to bring each patient to pathologic complete response (pCR) with a minimum of toxicity. Here we test the hypothesis that imaging (MR volume predictors) combined with core biopsy may be used to accurately select candidates who show early response and provide an option of treatment de-escalation at mid-therapy (12 weeks). Methods: Of 100 I-SPY 2 patients with pathologist-assessed core biopsies at the inter-regimen time point (~12 weeks through treatment) and pCR data, 87 also had serial MR images and were considered in this study. Eleven I-SPY 2 TRIAL pathologists independently provided a digital assessment of the presence or absence of residual invasive cancer from H&E stained, and any requested ancillary IHC, images from imaging-guided core biopsies. Pathology predicts pCR if there is a consensus of no invasive residual disease. We generated predictions for all (55) unique pairs over the 11 pathologists, where pCR is predicted if both pathologists find no invasive cells. MRI pCR prediction models were previously developed on an independent dataset of ~990 I-SPY 2 patients, and applied to this cohort. Volume-based prediction models were previously optimized within each subtype and predicted probability thresholds were selected over a range of positive predictive value (PPV). In this study, MR predicts pCR (positive test) if the predicted probability is above a threshold that yields a given PPV value. For each pathologist pair, we combined pathology-based and MR-based predictors into a predictive-RCB (pre-RCB); and pre-RCB predicts a patient as pCR (RCB0) if both MR and pathology predicts pCR. Predictive performance is assessed by calculating the mean and range of PPV and sensitivity.Results: 39% (34/87) of the patients in this study achieved pCR. Over all pairs of pathologists, on average 80% of pathology-only predicted pCRs were true pCRs (mean PPV = 80% [range: 69-92%]), and 74% of patients who achieved pCR were predicted pCR by pathology alone (mean sensitivity = 74% [65-82%]). We assessed combinations with MR probability thresholds at PPV levels 50%-70%; and observed the best balance of PPV and sensitivity for the pre-RCB when MR thresholds were set at 50% PPV level. At this threshold setting, the pre-RCB achieved a PPV = 92% [83-100%], meaning on average 92% of predicted pCRs were true pCRs, and this improvement in positive predictive performance over pathology alone is achieved with a lower but still-reasonable 53% sensitivity [33-62%].
Conclusion: Pre-RCB, which predicts a patient as pCR if both MR and inter-regimen pathology predicts pCR, provides clinically actionable accuracy for treatment de-escalation for early responders (PPV>90%). Adding a final MR review at the time of early surgery may further improve performance. Resulting from data presented in this abstract, the pre-RCB algorithm, including the final MR review, has been operationalized and will be used prospectively to identify patients who are highly likely to have already achieved pCR by the inter-regimen timepoint.
Citation Format: Sara J Venters, Wen Li, Denise M Wolf, Jodi M Carter, Molly E Klein, Kamaljeet Singh, Kimmie Rabe, I Tolgay Ocal, David Newitt, Christina Yau, Natsuko Onishi, Jessica Gibbs, Sunati Sahoo, Shuko Harada, Laila Khazai, Malini Harigopal, Alexander D Borowsky, Gregor Krings, Ronald Balassanian, Yunn-Yi Chen, Kimberley Cole, Sonal Shad, Barbara LeStage, Amy Delson, Sandra Finestone, Lamorna Brown-Swigart, I-SPY 2 Imaging Working Group, I-SPY 2 TRIAL Consortium, Laura Esserman, Laura van ‘t Veer, W Fraser Symmans, Nola M Hylton. Serial MRI and pathology combined to select candidates for therapy de-escalation in the I-SPY 2 TRIAL [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS4-10.
Collapse
|
6
|
van der Noordaa MEM, Yau C, Shad S, Osdoit M, Steenbruggen TG, de Croze D, Hamy AS, Lae M, Reyal F, Del Monte-Millán M, Martin M, Tarruella SL, Boughey JC, Goetz M, Hoskin T, Gould R, Valero V, Sonke G, van Seijen M, Wesseling J, Bartlett J, Edge S, Kim MO, Abraham J, Caldas C, Earl H, Provenzano E, Sammut SJ, Cameron D, Graham A, Hall P, MacKintosh L, Fan F, Godwin AK, Schwensen K, Sharma P, DeMichele A, Dunn J, Hiller L, Hayward L, Thomas J, Cole K, Pusztai L, van 't Veer L, Symmans F, Esserman L. Abstract GS4-07: Assessing prognosis after neoadjuvant therapy: A comparison between anatomic ypAJCC staging, residual cancer burden class and neo-bioscore. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-gs4-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in patients with breast cancer is associated with improved survival. Further assessment of the extent of residual disease, using the pathological anatomic American Joint Committee on Cancer staging method (ypStage) or the Residual Cancer Burden (RCB) method, have been shown to add prognostic information for patients with residual disease. Neo-Bioscore, an alternate system to classify response to NAC, includes clinical stage at diagnosis and biology and defines eight prognostic groups. The goal of this study was to compared three scoring systems (anatomic ypStage (7th ed), RCB Class and Neo-Bioscore) and assess whether RCB Class and Neo-Bioscore provide additional prognostic value in the context above anatomic ypStage, the most commonly used method for post-neoadjuvant residual disease assessment. Methods: Data from 5161 patients treated with NAC was pooled from 12 sites. Patients without clinical and pathological staging were excluded, as were patients with HER2+ breast cancer who did not receive neoadjuvant HER2-targeted therapy, leaving 3730 for analysis. PCR was defined as no residual invasive tumor in breast and nodes, i.e. RCB-0 or ypT0/Tis and ypN0. Patients with discordant pCR status by RCB Class vs ypStage (n=9) were excluded. Associations between each scoring system and event-free survival (EFS) were evaluated using the log rank test. EFS at 5 years was estimated using the Kaplan Meier method. Associations between Neo-Bioscore and EFS were assessed in the pCR group. For patients with residual disease, we assessed RCB and Neo-Bioscore within each ypStage. Analysis was performed overall and within subtype. Subgroups with <5 patients were excluded from the survival analyses. Results: ypAJCC staging, RCB class and Neo-Bioscore were all associated with EFS in the overall population and within each subtype (log rank p<0.0001). Of note, 13 patients with a Neo-Bioscore of 7 all recurred or died within 19 months of follow-up. Overall, 34% (1264/3721) of patients achieved a pCR. Their Neo-Bioscore ranges from 0-5, where 3% (37/1264) has a Neo-Bioscore of 5 despite achieving pCR. The Neo-Bioscore was not associated with EFS in case of a pCR, with EFS estimates at 5 years of 95%, 94%, 92%, 93%, 90% and 92% for Neo-Bioscores 0-5 respectively. As HR and HER2 status are components of the score, the range of Neo-Bioscore in the pCR group differs by subtype. However, similar to the overall analysis, the Neo-Bioscore was not prognostic within subtypes in case of pCR. Overall, among the patients who did not achieve pCR, both RCB class and Neo-Bioscore were associated with EFS within ypStages I, II and III. However, the ypStage within which RCB and Neo-Bioscore are prognostic is different for each subtype. RCB class was prognostic in ypStage I in both HR+ subtypes: patients with ypStage-I/RCB-I had significantly improved survival compared to patients with ypStage-I/RCB-II (5-year EFS: 100% vs 83% in HR+HER2- and 95% vs 77% in HR+HER2+). In contrast, for patients with triple negative breast cancer, RCB class was prognostic within ypStage II and III. Analysis by clinical stage and the components of the three systems that contribute most to prognosis will be presented. Conclusions: The degree of response to NAC adds important information to pCR versus residual disease. The Neo-Bioscore was not prognostic among patients with pCR, suggesting that clinical stage (including subtype and grade) adds little information in the setting of a pCR. In contrast, both RCB and Neo-Bioscore provide additional prognostic information to the conventional ypAJCC staging among non-pCR patients, suggesting that clinical stage, tumor biology as well as extent of residual disease all contribute to prognosis in the setting of residual disease after NAC.
Citation Format: Marieke EM van der Noordaa, Christina Yau, Sonal Shad, Marie Osdoit, Tessa G Steenbruggen, Diane de Croze, Anne-Sophie Hamy, Marick Lae, Fabien Reyal, Maria Del Monte-Millán, Miguel Martin, Sara Lopez Tarruella, I-SPY 2 TRIAL Consortium, Judy C Boughey, Matthew Goetz, Tanya Hoskin, Rebecca Gould, Vincent Valero, Gabe Sonke, Maartje van Seijen, Jelle Wesseling, John Bartlett, Stephan Edge, Mi-Ok Kim, Jean Abraham, Carlos Caldas, Helena Earl, Elena Provenzano, Stephen-John Sammut, David Cameron, Ashley Graham, Peter Hall, Lorna MacKintosh, Fang Fan, Andrew K Godwin, Kelsey Schwensen, Priyanka Sharma, Angela DeMichele, Janet Dunn, Louise Hiller, Larry Hayward, Jeremy Thomas, Kimberley Cole, Lajos Pusztai, Laura van 't Veer, Fraser Symmans, Laura Esserman. Assessing prognosis after neoadjuvant therapy: A comparison between anatomic ypAJCC staging, residual cancer burden class and neo-bioscore [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr GS4-07.
Collapse
Affiliation(s)
| | - Christina Yau
- 1University of California, San Francisco, San Francisco, CA
| | - Sonal Shad
- 1University of California, San Francisco, San Francisco, CA
| | | | | | | | | | | | | | | | - Miguel Martin
- 4Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | | | | | | | | | | | - Gabe Sonke
- 3Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | - John Bartlett
- 7Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Stephan Edge
- 8Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Mi-Ok Kim
- 1University of California, San Francisco, San Francisco, CA
| | - Jean Abraham
- 9University of Cambridge, Cambridge, United Kingdom
| | | | - Helena Earl
- 9University of Cambridge, Cambridge, United Kingdom
| | | | | | - David Cameron
- 10University of Edinburgh, Edinburgh, United Kingdom
| | - Ashley Graham
- 10University of Edinburgh, Edinburgh, United Kingdom
| | - Peter Hall
- 10University of Edinburgh, Edinburgh, United Kingdom
| | | | - Fang Fan
- 11University of Kansas, Kansas City, KS
| | | | | | | | | | - Janet Dunn
- 13University of Warwick, Coventry, United Kingdom
| | | | - Larry Hayward
- 14Western General Hospital, Edinburgh, United Kingdom
| | - Jeremy Thomas
- 14Western General Hospital, Edinburgh, United Kingdom
| | | | | | | | | | - Laura Esserman
- 1University of California, San Francisco, San Francisco, CA
| | | |
Collapse
|
7
|
Carter JM, Klein ME, Venters SJ, Rabe K, Ocal IT, Singh K, Wolf DM, Sahoo S, Harada S, Khazai L, Harigopal M, Borowsky AD, Krings G, Balassanian R, Chen YY, Cole K, Shad S, Delson A, Brown-Swigart L, Esserman L, van ‘t Veer L, Symmans WF. Abstract PS4-09: Pathologic features of the inter-regimen biopsy predict response to neoadjuvant therapy in the I-SPY 2 TRIAL. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-ps4-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: I-SPY 2 is a neoadjuvant platform trial open to patients with locally advanced, molecular high-risk breast cancer. In a concerted pursuit of mid-therapy response biomarkers, we evaluated inter-regimen biopsies, to identify patients who may be candidates for treatment de-escalation. In a pilot study, we observed that absence of carcinoma in an inter-regimen biopsy may predict pathologic complete response (pCR). In this expanded study of 100 participants, we sought to confirm that finding and assess pathologic features of the inter-regimen biopsy as predictors of tumor response to neoadjuvant therapy.
Methods: Digital H&E images of 100 inter-regimen (12 week) image-guided breast biopsies +/- ancillary immunohistochemistry (p63 and/or cytokeratin) were reviewed by 9 I-SPY affiliated pathologists to record 1) tumor bed and 2) presence/absence of residual invasive carcinoma (IC) (with tumor cellularity scored as 0-100%). The data set included 393 cores (mean 3.9 (2-4) cores/biopsy). Fisher’s exact t-test was used for association of presence/absence of IC with pCR, and tumoral hormone receptor (HR) and HER2 status. Association between biopsy tumor cellularity and residual cancer burden (RCB) indices used Pearson’s correlation.
Results: In the biopsy set, 84 (84%) had ≥80% inter-observer diagnostic agreement on both 1) presence of tumor bed and 2) presence/absence of IC (53 IC+ /31 IC-). IC+/IC- biopsies had equal numbers of evaluable tissue cores. The primary tumors were 63% HR+/37% HR-. The presence of IC in the biopsy correlated with tumoral HR/HER2 status (p=0.0014: 74%: HR+HER2-; 62%: TN; 60%: HR+HER2+; 10%: HR-HER2+). Of 31 patients with IC- biopsies, 25 (80%) went on to pCR, whereas only 7/53 (13%) of patients with IC+ biopsies had pCR, conferring an odds ratio for pCR of 26, Fisher p=7.5E-10. Overall, IC- biopsies had a positive predictive value (PPV) for pCR of 81%, with a PPV for HR- tumors of 94% vs. 67% for HR+ tumors (Table 1). In the 6 IC- biopsies from patients with non-pCR (“false-negatives”), most were HR+ (5/6, Table 1), and tumor bed size in the resection specimen was smaller than for IC+ biopsies with non-pCR: 276 mm2 (0.4-1000 mm2) vs. 1166 mm2 (1-11960 mm2). In contrast, the 46/53 IC+ biopsies in patients with non-pCR had a PPV for predicting non-pCR of 86%, (PPV for HR+ tumors: 94% vs. PPV for HR- tumors: 66%. Tumor cellularity in the biopsy (mean 37%, [2.5-93%]) did not correlate with RCB index (p=0.57) or RCB breast-only index (p = 0.17) at resection.
Conclusion: In this 100 biopsy set from the I-SPY2 trial, the absence of residual carcinoma in inter-regimen biopsies was highly predictive of pCR, particularly for HR- tumors. The “false-negative” biopsies (IC-/non-pCR) were predominantly HR+ tumors with small residual tumor beds at resection. Conversely, the presence of carcinoma in inter-regimen biopsies was highly predictive of non-pCR, particularly for HR+ tumors. These data demonstrate the utility, and the limitations, of the inter-regimen biopsy as one tool to identify patients who may benefit from therapeutic de-escalation.
Table 1: PPV for pCR/non-PCR by Inter-regimen Biopsy StatusInter-regimen biopsy with or without Invasive carcinoma (IC+/-)pCRnon-pCRPPV (Sensitivity) for pCR(IC- Biopsies)PPV (Sensitivity) for non-pCR(IC+ biopsies)IC- biopsiesAll25681% (78%)-HR+10567% (83%)-HR-15194% (75%)-IC+ biopsiesAll746-86% (88%)HR+236-94% (88%)HR-510-66% (91%)
Citation Format: Jodi M Carter, Molly E Klein, Sara J Venters, Kimmie Rabe, I Tolgay Ocal, Kamaljeet Singh, Denise M Wolf, Sunati Sahoo, Shuko Harada, Laila Khazai, Malini Harigopal, Alexander D Borowsky, Gregor Krings, Ronald Balassanian, Yunn-Yi Chen, Kimberley Cole, Sonal Shad, Amy Delson, Lamorna Brown-Swigart, I-SPY 2 TRIAL Consortium, Laura Esserman, Laura van ‘t Veer, W Fraser Symmans. Pathologic features of the inter-regimen biopsy predict response to neoadjuvant therapy in the I-SPY 2 TRIAL [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS4-09.
Collapse
|
8
|
Shad S, van der Noordaa M, Osdoit M, de Croze D, Hamy AS, Lae M, Reyal F, Martin M, Del Monte-Millán M, López-Tarruella S, Boughey JC, Goetz MP, Hoskin T, Gould R, Valero V, Sonke G, Steenbruggen TG, van Seijen M, Wesseling J, Bartlett J, Edge S, Kim MO, Abraham J, Caldas C, Earl H, Provenzano E, Sammut SJ, Cameron D, Graham A, Hall P, Mackintosh L, Fang F, Godwin AK, Schwensen K, Sharma P, DeMichele A, Dunn J, Hiller L, Hayward L, Thomas J, Cole K, Pusztai L, Van't Veer L, Symmans F, Esserman L, Yau C. Abstract PD13-02: Site of recurrence after neoadjuvant therapy: A multi-center pooled analysis. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-pd13-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Achieving a pathologic complete response (pCR) has been shown on the patient level to predict excellent long-term event-free survival outcomes. Residual cancer burden (RCB) quantifies the extent of residual disease for patients who did not achieve pCR. We have previously observed in the I-SPY 2 TRIAL that while metastatic events outside the central nervous system (CNS) were dramatically reduced in the setting of pCR, the incidence of CNS metastasis remained similar across RCB classes, raising the possibility that these CNS events may be independent of response in the breast. In this study, we evaluate the type and sites of recurrences by RCB in a large pooled dataset, which allows for analysis within subtype, to validate these findings. Methods: 5161 patients pooled across 12 institutions/trials with available RCB and event-free survival (EFS) data were included in this analysis. EFS was calculated as the interval between treatment initiation, and locoregional recurrence, distant recurrence or death from any cause; patients without event are censored at time of last follow-up. The median follow-up is 4.6 years. We summarized the EFS event type, further sub-dividing the distant recurrence events (DR) by their site of relapse (CNS-only, CNS and other sites, Non-CNS). We used a competing risk (Fine-Gray) model to assess which of these site-specific relapses differ between RCB classes and estimated the cumulative incidence of CNS-only and non-CNS events at 5 years. Analyses were performed across the entire study population and within HR/HER2 defined subtypes. Results: Among the 5161 subjects, there were 1164 EFS events, including 92 (7.9%) local recurrences (without distant recurrence and/or death) and 1072 distant recurrence-free survival (DRFS) events. Among the DRFS events, 158 patients died without a distant recurrence. 914 experienced distant recurrences, including 90 (9.8%) with CNS-only, 145 (15.9%) with CNS and other sites, 664 (72.6%) with non-CNS distant recurrence; 15 (1.6%) patients had missing recurrence site information. Table 1 summarizes the cumulative incidence of CNS-only and non-CNS recurrence at 5 years and the proportion of CNS-only recurrences among DR events by RCB class overall and within each HR/HER2 subtypes. The incidence of CNS-only recurrences was low and similar across RCB classes. In contrast, the incidence of non-CNS recurrences increases with increasing RCB. As a result, CNS-only recurrences are proportionally higher within the RCB-0 and RCB-I than in the RCB-II and RCB-III groups, largely because of the low DR event rate and relative low frequency of non-CNS recurrence events within the RCB-0 and RCB-I classes. Overall, 27% of the recurrences in the setting of pCR (RCB-0) are due to CNS-only recurrences.Conclusions: Consistent with previous studies, our large pooled analysis confirmed that CNS-only recurrences are uncommon but appear similar across RCB groups, independent of response, suggesting that the CNS is a treatment sanctuary site. In contrast, non-CNS recurrence rates increase as RCB increases. These findings suggest that inclusion of CNS-only recurrences as an outcome event may impact the association between neoadjuvant therapy response and long-term outcomes in the context of current therapies. Novel therapies that cross the blood brain barrier will be needed to impact CNS recurrence rates.
Table 1: Cumulative Incidence of CNS Only and non-CNS Distant Recurrences at 5 years and proportion of CNS-only events among DR eventsRCB Class0IIIIIIpOverall (5161)N16766622017806Cum. Inc. CNS Only2%2%2%1%0.627Cum. Inc. Non-CNS3%6%16%27%<0.001# CNS-Only / # DR events (%)26/96 (27%)14/74 (19%)39/443 (9%)11/301 (4%)HR-HER2- (1774)N770212590202Cum. Inc. CNS Only2%3%2%4%0.298Cum. Inc. Non-CNS4%11%19%42%<0.001# CNS-Only / # DR events (%)13/50 (26%)6/32 (19%)13/148 (9%)8/111 (7%)HR-HER2+ (572)N3766710029Cum. Inc. CNS Only1%5%5%0%0.022Cum. Inc. Non-CNS2%5%18%38%<0.001# CNS-Only / # DR events (%)4/17 (24%)3/10 (30%)6/31 (19%)0/13 (0%)HR+HER2+ (858)N31317229182Cum. Inc. CNS Only1%1%2%0%0.37Cum. Inc. Non-CNS2%3%15%26%<0.001# CNS-Only / # DR events (%)3/10 (30%)2/16 (12%)7/68 (10%)0/29 (0%)HR+HER2- (1957)N2172111036493Cum. Inc. CNS Only3%2%1%0.2%0.087Cum. Inc. Non-CNS5%4%13%20%<0.001# CNS-Only / # DR events (%)6/19 (32%)3/16 (19%)13/196 (7%)3/148 (2%)
Citation Format: Sonal Shad, Marieke van der Noordaa, Marie Osdoit, Diane de Croze, Anne-Sophie Hamy, Marick Lae, Fabien Reyal, Miguel Martin, María Del Monte-Millán, Sara López-Tarruella, I-SPY 2 TRIAL Consortium, Judy C Boughey, Matthew P Goetz, Tanya Hoskin, Rebekah Gould, Vicente Valero, Gabe Sonke, Tessa G Steenbruggen, Maartje van Seijen, Jelle Wesseling, John Bartlett, Stephen Edge, Mi-Ok Kim, Jean Abraham, Carlos Caldas, Helena Earl, Elena Provenzano, Stephen-John Sammut, David Cameron, Ashley Graham, Peter Hall, Lorna Mackintosh, Fan Fang, Andrew K Godwin, Kelsey Schwensen, Priyanka Sharma, Angela DeMichele, Janet Dunn, Louise Hiller, Larry Hayward, Jeremy Thomas, Kimberly Cole, Lajos Pusztai, Laura Van't Veer, Fraser Symmans, Laura Esserman, Christina Yau. Site of recurrence after neoadjuvant therapy: A multi-center pooled analysis [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD13-02.
Collapse
Affiliation(s)
- Sonal Shad
- 1University of California, San Francisco, San Francisco, CA
| | | | | | | | | | | | | | - Miguel Martin
- 4Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | | | | | | | | | | | | | - Gabe Sonke
- 2Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | | | - John Bartlett
- 7Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Stephen Edge
- 8Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Mi-Ok Kim
- 1University of California, San Francisco, San Francisco, CA
| | - Jean Abraham
- 9University of Cambridge, Cambridge, United Kingdom
| | | | - Helena Earl
- 9University of Cambridge, Cambridge, United Kingdom
| | | | | | - David Cameron
- 10University of Edinburgh, Edinburgh, United Kingdom
| | - Ashley Graham
- 10University of Edinburgh, Edinburgh, United Kingdom
| | - Peter Hall
- 10University of Edinburgh, Edinburgh, United Kingdom
| | | | - Fan Fang
- 11University of Kansas, Kansas City, KS
| | | | | | | | | | - Janet Dunn
- 13University of Warwick, Coventry, United Kingdom
| | | | - Larry Hayward
- 14Western General Hospital, Edinburgh, United Kingdom
| | - Jeremy Thomas
- 14Western General Hospital, Edinburgh, United Kingdom
| | | | | | | | | | - Laura Esserman
- 1University of California, San Francisco, San Francisco, CA
| | - Christina Yau
- 1University of California, San Francisco, San Francisco, CA
| | | |
Collapse
|
9
|
Breathnach AS, Riley PA, Shad S, Jownally SM, Law R, Chin PC, Kaufmann ME, Smith EJ. An outbreak of wound infection in cardiac surgery patients caused by Enterobacter cloacae arising from cardioplegia ice. J Hosp Infect 2006; 64:124-8. [PMID: 16899327 DOI: 10.1016/j.jhin.2006.06.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Accepted: 06/02/2006] [Indexed: 10/24/2022]
Abstract
This paper describes an outbreak of postoperative sternal wound infections. A cardiac surgeon noted a cluster of serious infections leading to wound dehiscence, despite the fact that none of his colleagues had noticed a rise in infection rates. The infections were predominantly with Enterobacter cloacae, and molecular typing and serotyping showed these isolates to be indistinguishable. Observation of the surgeon's practice revealed nothing untoward, and there were no infections among his patients operated on in another hospital. There appeared to be no significant difference between the modes of operation of the different surgeons. The operating theatres were screened to exclude an environmental source, with samples cultured on CHROMagar Orientation, a selective/differential medium designed for urine samples. Further questioning revealed one difference between the practices of the different surgeons; this surgeon used semi-frozen Hartmann's solution to achieve cardioplegia. The freezer used for this was swabbed and yielded E. cloacae, indistinguishable from the clinical isolates. It is hypothesized that this organism contaminated the freezer, and that the contamination was passed on to the ice/slush solution, thus infecting the patients. There have been no more cases since the freezer was replaced, a rigorous cleaning schedule instituted, and steps taken to reduce the possibility of any further contamination.
Collapse
Affiliation(s)
- A S Breathnach
- Department of Microbiology & Infection Control and Health Protection Agency Collaborating Centre, St George's Hospital, London, UK.
| | | | | | | | | | | | | | | |
Collapse
|
10
|
Abstract
Stentless porcine valves in the aortic position offer many theoretic advantages, but their clinical performance has not been adequately defined. We evaluated the clinical and echocardiographic results of 103 patients who had aortic valve replacement with the Toronto stentless porcine valve over a 2-year period. There were 67 men with a mean age of 68 years. The predominant native valve lesion was aortic stenosis (64%), and 4 patients had prosthetic valve dysfunction. Forty-two patients had concomitant procedures. The 30-day mortality rate was 3.3% (n = 2) for isolated valve replacement and 5.8% (n = 6) for the series. The sole determinant of early death was poor left ventricular function. There were three late deaths due to non-valve-related complications over a median follow-up of 11.87 months. In addition, prosthetic valve endocarditis developed in 1 patient, necessitating a homograft valve replacement at 6 weeks. Doppler echocardiography performed at 3 to 6 months showed low peak and mean transvalvular gradients, with no substantial change at 1 year. None of the patients showed signs of clinically significant aortic regurgitation, although echocardiography demonstrated trivial or mild regurgitation in 12 patients at discharge or early follow-up, which was less marked or absent at 1 year. We conclude that the Toronto stentless porcine valve appears to offer promising early results.
Collapse
Affiliation(s)
- K Wong
- Royal Brompton Hospital, London, England
| | | | | | | | | | | |
Collapse
|