Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with early breast cancer

The European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with early breast cancer were updated and published online in 2023, and adapted, according to previously established standard methodology, to produce the Pan-Asian adapted (PAGA) ESMO consensus guidelines for the management of Asian patients with early breast cancer. The adapted guidelines presented in this manuscript represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with breast cancer representing the oncological societies of China (CSCO), Indonesia (ISHMO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO), co-ordinated by ESMO and KSMO. The voting was based on scientific evidence and was independent of the current treatment practices, drug access restrictions and reimbursement decisions in the different Asian regions represented by the 10 oncological societies. The latter are discussed separately in the manuscript. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with early breast cancer across the different regions of Asia, drawing on the evidence provided by both Western and Asian trials, whilst respecting the differences in screening practices, molecular profiling, as well as the age and stage at presentation. Attention is drawn to the disparity in the drug approvals and reimbursement strategies, between the different regions of Asia.

Pathological and Oncologic Outcomes of Consolidation Chemotherapy in Locally Advanced Rectal Cancer after Neoadjuvant Chemoradiation

Objective: The current standard of care for locally advanced rectal cancer is associated with multimodality therapy. Neoadjuvant chemoradiation significantly decreased the locoregional recurrence rate and improved survival. However, distant metastasis develops rather than local recurrence, which becomes the leading cause of death. This study aimed to evaluate the oncological outcomes of total neoadjuvant therapy (TNT) in locally advanced rectal cancer. Materials and Methods: This retrospective study recruited 18 patients diagnosed with locally advanced rectal adenocarcinoma (cT3-4 or cN1-2), treated with consolidation TNT. The primary endpoint was pathological complete response (pCR). The secondary endpoint included postoperative outcomes, local recurrences, and distant metastases. Results: The pathologic complete response was observed in 27.8% of consolidation therapy cases. Downstaging of the T-category was achieved in 10 (55.6%) patients, and downstaging of the N-category was achieved in 14 (77.8%) patients. Only one patient who achieved pCR developed distant metastasis, whereas all patients with pathological stage III developed distant metastasis. Conclusions: TNT is a promising approach for patients with locally advanced rectal cancer. This strategy improved complete pathologic response rates in TNT, and pCR was found to be associated with fewer local recurrences and greater disease-free survival.

Follow-Up Strategies and Detection of Recurrent Breast Cancer in the Modern Era

BACKGROUND

Regular history assessments and physical examination with annual breast imaging have been recommended as the standard surveillance protocol for breast cancer patients who underwent curative-intent therapy. Based on randomized studies conducted in the 2000s, surveillance with regular chest or abdominal imaging, chemistry panels, or tumor marker measurements does not improve survival in such patients. Given the remarkable recent improvements of systemic therapy, we hypothesized that more intensive surveillance may lead to early detection and improve treatment outcomes in the modern era.

METHODS

We retrospectively evaluated the follow-up strategies and benefits of investigations used in usual practice. Breast cancer patients who had initial adjuvant therapy were recruited and classified according to the receipt of standard follow-up (history, physical examination, and annual breast imaging) or alternative follow-up (surveillance with at least annual chest or abdominal imaging or biannual liver function testing). The primary outcome was overall survival. Secondary outcomes included disease-free survival and the indicator of recurrence detection.

RESULTS

Of 412 recruited patients, 213 (51.7%) and 199 patients (49.3%) were included in the standard follow-up group and alternative follow-up group, respectively. Among 90 patients (21%) with disease recurrence, the most frequent indicators of recurrence were newly reported symptoms or physical examination abnormalities (64%), followed by abnormal breast imaging (23%) and abnormal chest X-ray (10%). After a median follow-up of 85 months, approximately 90% of patients remained alive after 5 years in both groups. The mean overall survival was similar between the standard and alternative follow-up groups (154.5 months vs. 151.9 months, p = 0.54). There was no difference in terms of the proportion of interval visits, specific cancer treatment received, and disease-free survival.

CONCLUSION

Standard follow-up with history assessments, physical examination, and annual breast imaging remains the recommended surveillance strategy in the modern era. Alternative follow-up strategy did not improve oncologic outcomes.

Disparities in Access to Systemic Treatment for Breast Cancer in Thailand and Major Asian Territories

Purpose

Methods

Results

Conclusion

Patterns and outcomes of immune-related adverse events in solid tumor patients treated with immune checkpoint inhibitors in Thailand: a multicenter analysis

BACKGROUND

Most immune-related adverse event (irAE) patterns and treatment guidelines are based on western clinical data. We evaluated the incidence and patterns of irAEs in patients treated with immune-checkpoint inhibitors (ICI) in Thailand.

METHODS

All solid tumor patients treated with ICIs were retrospectively reviewed in a multicenter analysis. The study aims to evaluate the incidence of irAEs and their characteristics, treatments, outcomes, and impact on survival. All irAEs were graded using the CTCAE version 4.0. Characteristics of irAEs including time to onset, duration of irAEs, specific treatments, and outcomes of irAEs were reviewed. The Chi-square or Fisher's exact test was used to compare variables. Overall survival (OS) was estimated by the Kaplan-Meier method, and compared by the log-rank test. A p-value < 0.05 was considered statistically significant.

RESULTS

irAEs of any grade were observed in 98 of 414 patients (24%), whereas grades 3-4 irAEs were observed in 5.6%. The majority of patients (78%) were treated with monotherapy ICI (anti-PD1/PD-L1 92%). The most common all-grade irAEs were hypothyroidism (7.5%), hepatitis (6.5%), and rash (4.8%). Median onset of overall irAEs was 63 days. Pancreatitis and pneumonitis had the earliest onset at 30 and 34 days, respectively. ICIs were rechallenged in 68 of 98 patients with irAE. Eleven of sixty-eight patients (11.2%) with initial irAE had reoccurrence after ICI rechallenge. Based on a multivariate analysis, pre-existing hypothyroidism, ICI used in a clinical trial setting, and combinations of ICI/ICI were independent factors predicting irAE occurrence. Patients with irAE had a statistically significant longer overall survival (OS) when compared to patients without irAE (p = 0.019). A multivariate analysis revealed that occurrence of irAE was an independent prognostic factor for OS (HR 0.70, 95% CI 0.51-0.96; p = 0.028).

CONCLUSION

irAE was commonly observed in Thai cancer patients treated with ICIs. Most irAEs were low-grade and manageable. Re-occurrence of irAE after re-challenging ICI was not uncommonly observed. Patients who experienced irAEs might have significantly longer OS compared to patients without irAEs. However, OS in this study should be interpreted with caution since it might be affected by various tumor types, treatment settings, dosing schedule, and ICI combinations.

Predictive significance of cancer related-inflammatory markers in locally advanced rectal cancer

BACKGROUND

Locally advanced rectal cancer is treated using neoadjuvant chemoradiation (nCRT), followed by total mesorectal excision (TME). Tumor regression and pathological post-treatment stage are prognostic for oncological outcomes. There is a significant correlation between markers representing cancer-related inflammation, including high neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) and unfavorable oncological outcomes. However, the predictive role of these markers on the effect of chemoradiation is unknown.

AIM

To evaluate the predictive roles of NLR, MLR, and PLR in patients with locally advanced rectal cancer receiving neoadjuvant chemoradiation.

METHODS

Patients (n = 111) with locally advanced rectal cancer who underwent nCRT followed by TME at the Minimally Invasive Surgery Unit, Siriraj Hospital between 2012 and 2018 were retrospectively analyzed. The associations between post-treatment pathological stages, neoadjuvant rectal (NAR) score and the pretreatment ratios of markers of inflammation (NLR, MLR, and PLR) were analyzed.

RESULTS

Clinical stages determined using computed tomography, magnetic resonance imaging, or both were T4 (n = 16), T3 (n = 94), and T2 (n = 1). The NAR scores were categorized as high (score > 16) in 23.4%, intermediate (score 8-16) in 41.4%, and low (score < 8) in 35.2%. The mean values of the NLR, PLR, and MLR correlated with pathological tumor staging (ypT) and the NAR score. The values of NLR, PLR and MLR were higher in patients with advanced pathological stage and high NAR scores, but not statistically significant.

CONCLUSION

In patients with locally advanced rectal cancer, pretreatment NLR, MLR and PLR are higher in those with advanced pathological stage but the differences are not significantly different.

Association between dietary patterns and disease recurrence in Thai colorectal cancer patients

Beside established anti-cancer treatment, dietary modification is one of the most promising approaches for reducing the probability of colorectal cancer (CRC) recurrence. Many Western studies showed a relationship between shortened survival and increased amounts of Western diet (meat and processed meat). Given that Thai food is dissimilar to Western diet, we aimed to explore the association between dietary patterns and disease recurrence among Thai CRC patients.Early-stage CRC patients who were disease-free at the end of a 2-year period or patients with disease recurrence within 2 years were enrolled. Patients were administered a food frequency questionnaire to evaluate their dietary lifestyle. Quantitative comparison within individual food groups among patients who were disease-free and among those with recurrence was performed. Proportion of patients with recurrence and disease-free survival was compared between patients who had consumed the lowest and highest tertile of each dietary pattern.A total of 225 CRC patients were enrolled (151 disease-free and 74 recurrence). There were no significant differences in demographic or tumor parameters between patients with or without disease recurrence. From the questionnaire, 45 food items were assigned to 1 of 12 food groups according to similarity in nutritional profile. Patients who consumed high amounts of pickled fish or chili-paste had significantly lower recurrence rates compared to patients who had never eaten those foods (P < .01). From the factor analysis, meat/wheat, vegetarian, and fast-food/processed fruit patterns were identified as the major dietary patterns. There was no significant association between intakes of individual dietary patterns and CRC recurrence.Among CRC patients with Thai dietary lifestyles there was no association between meat/wheat, fast-food/processed fruit, or vegetarian dietary patterns and CRC recurrence. Greater consumption of some unique Thai foods, such as chili-paste or pickled fish, may relate to better outcomes for CRC patients.

From presentation to paper: Gender disparities in oncological research

Gender disparities in scientific publications have been identified in oncological research. Oral research presentations at major conferences enhance visibility of presenters. The share of women presenting at such podia is unknown. We aim to identify gender-based differences in contributions to presentations at two major oncological conferences. Abstracts presented at plenary sessions of the American Society of Clinical Oncology (ASCO) Annual Meetings and European Society for Medical Oncology (ESMO) Congresses were collected. Trend analyses were used to analyze female contribution over time. The association between presenter's sex, study outcome (positive/negative) and journals' impact factors (IFs) of subsequently published papers was assessed using Chi-square and Mann-Whitney U tests. Of 166 consecutive abstracts presented at ASCO in 2011-2018 (n = 34) and ESMO in 2008-2018 (n = 132), 21% had female presenters, all originating from Northern America (n = 17) or Europe (n = 18). The distribution of presenter's sex was similar over time (p = 0.70). Of 2,425 contributing authors to these presented abstracts, 28% were women. The proportion of female abstract authors increased over time (p < 0.05) and was higher in abstracts with female (34%) compared to male presenters (26%; p < 0.01). Presenter's sex was not associated with study outcome (p = 0.82). Median journals' IFs were lower in papers with a female first author (p < 0.05). In conclusion, there is a clear gender disparity in research presentations at two major oncological conferences, with 28% of authors and 21% of presenters of these studies being female. Lack of visibility of female presenters could impair acknowledgement for their research, opportunities in their academic career and even hamper heterogeneity in research.

Post-Operative Concurrent Chemoradiation for Patients with Non-Squamous Cell Carcinoma of Head and Neck: A Retrospective Cohort of the Uncommon Cancers

Background:

Non-squamous cell carcinoma of the head and neck (HNnSCCA) is a rare tumor. Surgery is the standard treatment for resectable non-metastatic patients. Post-operative radiation (RT) is indicated for high-risk patients. No data from the randomized controlled trial utilizing post-operative concurrent chemoradiation (CCRT) is available. This study was aimed to determine the benefit of post-operative CCRT in the patients with resectable non-metastatic HNnSCCA.

Methods:

We retrospectively reviewed data of 139 patients with HNnSCCA (excluding nasopharyngeal, neuroendocrine, and skin cancers) who underwent surgery and post-operative radiation (RT) at Siriraj Hospital from 2009–2015.

Results:

Ninety-nine of the 139 patients had RT alone and 40 had CCRT. More patients receiving CCRT had ≥ one high-risk feature (80% CCRT vs. 57.6% RT; p=0.018). Five-year disease-free survival (DFS) and overall survival (OS) did not differ between the groups (58.6% CCRT vs. 68.2% RT; p=0.35 and 81.7% CCRT vs. 81.0% RT; p=0.35, respectively). Interestingly, post-operative CCRT was independently associated with significantly superior DFS (hazard ratio, HR 0.29; 95% confidence interval, CI 0.10 to 0.86; p=0.02) and OS (HR 0.08; 95% CI 0.01 to 0.43; p=0.003) according to multivariable analyses.

Conclusion:

Post-operative CCRT was associated with better survival in high-risk patients with resectable non-metastatic HNnSCCA comparing with post-operative RT alone. Post-operative CCRT might be considered as a treatment option for these patients.

From presentation to paper: Gender disparities in oncological research

10523

Background: Gender discrepancies have been identified in authorships of scientific publications, grant applications, and peer review in many disciplines, including oncology. The exact share of women presenting results of oncological studies at large conferences is unknown, while the oral presentation of a study at such a podium enhances the international visibility and recognition of the presenting person. Therefore, we aim to identify gender-based differences in contributions to presentations at two major oncological conferences. Methods: We collected consecutive abstracts presented at the plenary sessions of the American Society of Clinical Oncology (ASCO) Annual Meetings and presidential sessions of the European Society for Medical Oncology (ESMO) Congresses. Sex of the presenters and abstract authors, study results (positive vs. negative), and subsequently published papers were identified. Chi square tests were used to compare the distribution of sex over time. The association between presenter’s or last author’s sex and study outcome and impact factors were analyzed using Chi square tests and Mann-Whitney U tests, respectively. Results: Of available abstracts presented at ASCO between 2011 and 2018 (N = 34), and ESMO between 2008 and 2018 (N = 132), presenters were female in 24% and 21%, respectively. Female last authors were seen in 21% and 20% of these ASCO and ESMO abstracts. Of all contributing authors to these ASCO (N = 569) and ESMO (N = 1851) abstracts, 31% and 27% were female, respectively. The distribution of male and female ASCO and ESMO presenters (P = 0.580, P = 0.707, respectively) and abstract authors (P = 0.429, P = 0.062) was similar over the years. Of all abstracts, sex of the presenter or last abstract author were not associated with study outcomes (P = 0.718, P = 0.4331), nor with impact factor of subsequently published papers (P = 0.209, P = 0.661). Conclusions: There is a clear gender disparity in the presentation of oncological research at two main conferences, with less than a third of abstract authors female and less than a quarter of these studies presented by a woman. The lack of visibility of female researchers at presentations on these conferences could impair the acknowledgement for their research, opportunities in their academic career, and even hamper heterogeneity and outcomes in research.

Risk Factors for Chemotherapy-Related Toxicity and Adverse Events in Elderly Thai Cancer Patients: A Prospective Study

OBJECTIVES

To assess factors predisposing to severe chemotherapy-related toxicity and adverse events (AEs) and dose modification in aging cancer patients.

METHODS

Cancer patients aged ≥70 years scheduled to receive the first cycle of a new chemotherapy regimen were enrolled. On the day of starting chemotherapy, demographic data, performance status (PS), and geriatric parameters were recorded. AEs and chemotherapy modification were recorded. Quality of life (QOL) was assessed at baseline and 3 months after starting chemotherapy or at the end of chemotherapy.

RESULTS

We included 151 patients (mean age, 76.4 years) with gastrointestinal (47%), lung (24%), breast (9%), or genitourinary (6%) cancer. All-grade and severe AEs occurred in 83 and 42% of patients, respectively; 51.6% of patients required chemotherapy modification due to toxicities. A higher incidence of severe AEs (71% vs. 39%, p = 0.01) and poorer QOL was found in patients with PS 2 than in those with PS 0-1. Patients with PS 2 or who received palliative-intent chemotherapy or had multiple comorbidities were more likely to discontinue chemotherapy because of toxicity.

CONCLUSIONS

PS remains a key predictor of chemotherapy-related toxicity in elderly patients. PS 2 was correlated with higher incidence of severe AEs, premature treatment discontinuation, and worsening QOL after treatment.

Postoperative concurrent chemoradiation (CCRT) for non-squamous cell carcinoma (NSCCA) of head and neck

e17582

Background: Surgery is the mainstay of treatment for resectable non-metastatic NSCCA of head and neck. Postoperative radiation (RT) is delivered to patients (pt) with high risk for recurrence. Unlike the squamous cell counterpart where survival advantage from adding chemotherapy (CMT) as a radio-sensitizer is evident, the benefit of CCRT is uncertain in NSCCA pt. We hypothesized that CCRT would improve disease free survival (DFS), comparing to RT alone. Methods: NSCCA of head and neck pt who underwent curative surgery and RT at Siriraj hospital from 2006 to 2015 were included in this retrospective study. Patients with residual tumor after surgery or neuroendocrine histology were excluded. The primary outcome was DFS. The secondary outcome was overall survival (OS). Results: We included 139 pt, 99 (71.2%) had RT while 40 (28.8%) had CCRT. Baseline characteristics, including age, gender, primary site, histology and radiation dose were similar between 2 groups. Salivary gland was the most common primary site (67.6%). The most common histology was adenoid cystic carcinoma (35.3%), followed by mucoepidermoid carcinoma (25.9%). Patients who received RT alone had earlier stage (Stage I 29.3%, Stage IVa 14.1%), compared to CCRT group (Stage I 7.7%, Stage IVa 38.5%), p = 0.003. High risk features (positive margin, extranodal extension or ≥ 2 cervical lymph nodes metastasis) were found in 42% and 62% of pt with RT and CCRT, respectively (p = 0.03). In CCRT group, 92% of pt received cisplatin every 3 weeks during RT period. With the median follow-up time of 54.9 months, 3-year DFS was 79.4% and 79.5% in RT and CCRT groups, respectively (p = 0.22). There was no significant difference in 3-year OS between RT and CCRT groups (89.2% vs 89.9%, p = 0.76). Among pt with high-risk features (n = 67, 48.2%), 3-year DFS and OS were not significantly different between treatment groups. However, among pt without high-risk features, 3-year DFS in RT group was significantly higher than CCRT group (84.8% vs 79.0%, p = 0.04). Conclusions: This study demonstrates no survival benefit from adding concurrent CMT to RT following curative surgery in NSCCA of head and neck. Moreover, addition of CMT may be detrimental in pt without high-risk features.

Efficacy of ginger for prophylaxis of chemotherapy-induced nausea and vomiting in breast cancer patients receiving adriamycin-cyclophosphamide regimen: a randomized, double-blind, placebo-controlled, crossover study

PURPOSE

The purpose of this study is to determine the efficacy of ginger for reducing chemotherapy-induced nausea and vomiting (CINV) in breast cancer patients receiving adriamycin and cyclophosphamide (AC) regimens.

METHODS

We enrolled breast cancer patients receiving AC who experienced moderate to severe nausea or vomiting during the first chemotherapy cycle. Subjects were randomized to receive a 500-mg ginger capsule or placebo twice a day for 5 days starting on the first day of the second AC cycle and were switched to the other treatment in the third cycle. All participants also received ondansetron and dexamethasone for CINV prophylaxis. Nausea severity was recorded once a day during the first 5 days of each cycle. The primary outcome was reduction in nausea score.

RESULTS

Thirty-four subjects (68 cycles of AC) were enrolled. Mean (range) maximum nausea score in the first AC cycle was 58 (40-90). Thirty-three subjects (97 %) received the same AC doses in the second as in the third cycle. Mean (±standard error) maximum nausea scores in patients receiving ginger and placebo were 35.36 (±4.43) and 32.17 (±3.71), respectively. The difference in mean maximum nausea scores was 3 (95 % confidence interval, -3 to 9; P = 0.3). There were no significant differences between ginger and placebo in terms of vomiting incidence and severity, rescue medication use, chemotherapy compliance, and adverse events.

CONCLUSIONS

Ginger (500 mg) twice daily was safe, but conferred no additional benefit in terms of reducing nausea severity in breast cancer patients receiving AC and ondansetron and dexamethasone for CINV prophylaxis.

Factors that predict recurrence later than 5 years after initial treatment in operable breast cancer

BACKGROUND

Occasionally, breast cancer relapses more than 5 years after initial treatment, sometimes with highly aggressive disease in such late-recurring patients. This study investigated predictors of recurrence after more than 5 years in operable breast cancer.

METHODS

We retrospectively analyzed data from patients with recurrent breast cancer treated at Siriraj Hospital. Patients were divided into those whose relapse times were longer or shorter than 5 years. Factors that predicted late recurrence were analyzed in both the overall population and the luminal subgroup. Patterns of relapse, changes in biomarkers, and time to disease progression after first relapse were also recorded.

RESULTS

We included 300 women whose breast cancers recurred between 2005 and 2013, of whom 180 had recurrence within 5 years of diagnosis and 120 later than 5 years (median time to recurrence: 45.43 months; range: 4.4-250.3 months). Tumors larger than 2 cm, lymph node metastasis, and high nuclear grade were related with early recurrence. Estrogen receptor-positive, progesterone receptor-positive, and HER2(-) disease predicted late recurrence. Almost all late-relapsing patients with luminal tumors had high estrogen receptor (ER(+)) titers (≥50 %) and HER2(-) disease. Liver and brain were the most common early recurrence sites. Biomarkers did not significantly change by time of recurrence.

CONCLUSIONS

ER(+)/PR(+) and HER2(-) patients have higher risk of recurrence later than 5 years, especially in patients with high ER titer and low nuclear grade. Larger and node-positive tumors had higher risk of early recurrence.

HER2 drives luminal breast cancer stem cells in the absence of HER2 amplification: implications for efficacy of adjuvant trastuzumab

Although current breast cancer treatment guidelines limit the use of HER2-blocking agents to tumors with HER2 gene amplification, recent retrospective analyses suggest that a wider group of patients may benefit from this therapy. Using breast cancer cell lines, mouse xenograft models and matched human primary and metastatic tissues, we show that HER2 is selectively expressed in and regulates self-renewal of the cancer stem cell (CSC) population in estrogen receptor-positive (ER(+)), HER2(-) luminal breast cancers. Although trastuzumab had no effects on the growth of established luminal breast cancer mouse xenografts, administration after tumor inoculation blocked subsequent tumor growth. HER2 expression is increased in luminal tumors grown in mouse bone xenografts, as well as in bone metastases from patients with breast cancer as compared with matched primary tumors. Furthermore, this increase in HER2 protein expression was not due to gene amplification but rather was mediated by receptor activator of NF-κB (RANK)-ligand in the bone microenvironment. These studies suggest that the clinical efficacy of adjuvant trastuzumab may relate to the ability of this agent to target the CSC population in a process that does not require HER2 gene amplification. Furthermore, these studies support a CSC model in which maximal clinical benefit is achieved when CSC targeting agents are administered in the adjuvant setting. Cancer Res; 73(5); 1635-46. ©2012 AACR.

Pituitary metastasis from renal cell carcinoma: a case report with literature review

A 52-year-old man suffered from visual disturbance for 5 months. He then developed malaise, constipation and anorexia with significant weight loss. Physical examination showed noticeable signs of hypothyroidism, such as slurred speech, dry skin, macroglossia, myoedema and slow relaxation of ankle reflexes. In addition, eye exam showed abnormal visual acuity with left homonymous hemianopia. A large mass was found at right scapular region. Endocrinologic investigation results were compatible with secondary hypothyroidism with adrenal insufficiency. Subsequent CT brain revealed an enhancing mass at pituitary gland and also a mass at right occipital lobe with surrounding edema. CT of chest demonstrated multiple lung nodules, right scapular mass and incidentally revealed 8.7-cm hypervascular mass at left kidney. The final diagnosis was renal cell carcinoma with bone, lung, brain and pituitary metastasis. He received hormone replacement therapy as well as bisphosphonate and brain radiation. Following treatments, he was able to return to work with recovery of visual impairment. Pituitary metastasis is a rare condition. Our patient presented with symptoms of hypothyroidism which may mimic pituitary adenoma, but had other clues of malignancy such as significant weight loss and scapular mass. The most common cancers that occasionally metastasize to pituitary gland are breast and lung cancer. Previously, renal cell carcinoma with pituitary metastasis has been reported. Unlike ourpatient, most of these cases developed metachronous pituitary metastasis.

A phase II study of the combination of gemcitabine plus carboplatin as the neoadjuvant treatment in locally advanced breast cancer

OBJECTIVE

Although anthracycline-based regimen is standard neoadjuvant chemotherapy (NAC) for locally advanced breast cancer (LABC), there is some concern over its toxicities such as alopecia and cardiotoxicity. Gemcitabine is another active agent in metastatic breast cancer after failure to anthracycline with less toxicity. The objective of the present study is to evaluate the efficacy and safety of the combination of gemcitabine and carboplatin as NAC in LABC.

MATERIAL AND METHOD

Patients with histologically confirmed LABC (T3, T4 or N2 and M0) were included. Patients were scheduled to receive 3 cycles of neoadjuvant GC (gemcitabine 1,000 mg/m2 D1, D8 and carboplatin AUC x 5 D1) every 21 days. Patients with clinical response underwent surgery and additional 3 cycles of adjuvant GC. Primary endpoint was clinical response rate whereas secondary endpoints included pathological response, DFS, OS and toxicity.

RESULTS

Between 2004 and 2007, 40 LABC patients were enrolled. Of 40 patients, 35 were evaluable for efficacy and 40 for toxicity. Twenty-three out of 35 patients (65%) obtained cPR. Among 22 patients who had clinical response and who underwent surgery, overall pathological response rate was 51.5% with 1-pCR (2.9%) and 17-pPR (48.5%). All 7 triple-negative patients had pathological response (1-pCR, 6-pPR). At median follow-up of 59 months, median DFS and OS were not reached. Five-year OS and DFS were 67% and 62%, respectively Major adverse effect was myelosuppression without fatal complications.

CONCLUSION

The combination GC was feasible and well-tolerated for LABC in neoadjuvant setting. Triple-negative subgroup seems to have high response to GC.

Treatment of locally advanced rectal cancer: Controversies and questions

Rectal cancers extending through the rectal wall, or involving locoregional lymph nodes (T3/4 or N1/2), have been more difficult to cure. The confines of the bony pelvis and the necessity of preserving the autonomic nerves makes surgical extirpation challenging, which accounts for the high rates of local and distant relapse in this setting. Combined multimodality treatment for rectal cancer stage II and III was recommended from National Institute of Health consensus. Neoadjuvant chemoradiation using fluoropyrimidine-based regimen prior to surgical resection has emerged as the standard of care in the United States. Optimal time of surgery after neoadjuvant treatment remained unclear and prospective randomized controlled trial is ongoing. Traditionally, 6-8 wk waiting period was commonly used. The accuracy of studies attempting to determine tumor complete response remains problematic. Currently, surgery remains the standard of care for rectal cancer patients following neoadjuvant chemoradiation, whereas observational management is still investigational. In this article, we outline trends and controversies associated with optimal pre-treatment staging, neoadjuvant therapies, surgery, and adjuvant therapy.

Activation of an IL6 inflammatory loop mediates trastuzumab resistance in HER2+ breast cancer by expanding the cancer stem cell population

Although inactivation of the PTEN gene has been implicated in the development of resistance to the HER2 targeting antibody trastuzumab, the mechanisms mediating this resistance remain elusive. We generated trastuzumab resistant cells by knocking down PTEN expression in HER2 overexpressing breast cancer cell lines and demonstrate that development of trastuzumab resistance in these cells is mediated by activation of an IL6 inflammatory feedback loop leading to expansion of the cancer stem cell (CSC) population. Long term trastuzumab treatment generates highly enriched CSCs which display an EMT phenotype secreting over 100-fold more IL6 than parental cells. An IL6 receptor antibody interrupted this inflammatory feedback loop reducing the cancer stem cell population resulting in decreased tumor growth and metastasis in mouse xenographs. These studies demonstrate that trastuzumab resistance may be mediated by an IL6 inflammatory loop and suggest that blocking this loop may provide alternative strategy to overcome trastuzumab resistance.

Abstract 3470: HER2 drives luminal breast cancer stem cells in the absence of HER2 amplification: Implications for efficacy of adjuvant trastuzumab

Although current breast treatment guidelines limit the use of HER2 blocking agents such as trastuzumab to women whose tumors display HER2 gene amplification, recent retrospective analysis by Paik et al., have suggested that a wider group of patients may benefit from this therapy. Utilizing breast cancer cell lines, mouse xenograft models and primary human tumors and metastatic tissues, we provide a potential molecular explanation for these unanticipated clinical finding by demonstrating that HER2 is selectively expressed in the cancer stem cell (CSC) population in luminal ER+ breast cancers that do not display HER2 amplification. Furthermore, we demonstrate that the effects of trastuzumab on mouse tumor xenografts are highly dependent on the timing of administration. While the effects of trastuzumab on established tumors are limited to those with HER2 amplification, when this HER2 blocker is given immediately after tumor inoculation simulating an adjuvant setting, it significantly inhibits the growth of luminal tumors in the absence of HER2 amplification. In addition, HER2 expression is increased in luminal tumors propagated in mouse tibias as compared to primary tumors grown in mammary fat pads. Utilizing co-culture experiments with human osteocytes, we provide evidence that this regulated expression of HER2 is mediated by RANK ligand present in the bone microenvironment. The clinical relevance of these studies is demonstrated in breast cancer tissues by the co-expression of HER2 and CSC marker ALDH1 in a subset of cells which are selectively found at the invasive tumor front in luminal breast cancers. Recapitulating the mouse xenograft studies, we demonstrate increased expression of HER2 in bone metastasis compared to matched primary tumors in 8 patients with luminal breast cancer. Our results have significant clinical implications since they suggest that the benefits of adjuvant HER2 targeting therapies may extend to patients with luminal breast cancers who are currently classified as HER2-negative. Furthermore, these results support the cancer stem cell hypothesis and emphasize the clinical importance of targeting cancer stem cells in the adjuvant setting.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 3470. doi:1538-7445.AM2012-3470

P4-01-02: Endocrine Resistance: Mechanism, Tumorigenic Capacities, and New Therapeutic Strategies

Background

Endocrine therapy is the most effective therapies for estrogen receptor positive (ER+) breast cancer, but resistance is still a major clinical problem. Tumor initiating cells (TICs) in drug resistant tumors are believed to be part of the contributing factors for tumor relapse. Here we focused on the TICs and how they are related to HER2 expression and its downstream factors in acquired endocrine resistance models.

Materials and Methods: We have established a panel of endocrine resistant cell models through long-term treatment with tamoxifen (Tam, 10−7M, &gt;6 months). Resistance to tamoxifen treatment in cells (TamR) was confirmed by growth curve assays (Celigo, Cyntellect Inc., San Diego, CA). In vitro mammosphere assays were applied to assess the mammosphere forming ability of parental and resistant cells. Aldefluor assays (StemCell Technology) were performed to measure the aldehyde dehydrogenase (ALDH-1) expressing cell population as a marker of TICs. Flow analysis was performed to evaluate HER2 expression in the ALDH subpopulations of both parental and TamR cells. Immunofluorescence staining was further used to detect the expression of ER, HER2, phosphorylated STAT3, and β-catenin in sorted ALDH+/− subpopulations.

Results: We found that endocrine resistant cells have a higher mammosphere forming ability than their parental counterparts. In addition, we showed that the ALDH+ subpopulation was significantly upregulated in all TamR derivative lines.

Cancer anemia survey in Division of Medical Oncology at Siriraj Hospital (CAS)

BACKGROUND

Causes of anemia in cancer patients are multifaceted and include such factors as nutritional deficiency anemia, anemia of malignancy and treatment-related anemia. Chemotherapy, especially a platinum-based regimen, is well recognized to cause anemia. Anemia results in decrease of functional capacity, lower performance status, poor compliance and adverse prognosis. Optimal management of anemia in cancer patients is an essential component of cancer treatment. Previously, there was no information about this condition available in Thailand.

OBJECTIVE

1) To evaluate frequency, characteristics of anemia and treatments of anemia in our cancer patients who received chemotherapy treatment. 2) To identify the factors that influence hemoglobin (Hb) level in cancer patients especially chemotherapy regimens.

MATERIAL AND METHOD

Patients with diagnosis of solid malignancy who were scheduled to receive chemotherapy for least 4 cycles between June 2006 and December 2007 were included. All enrolled patients' data which included demographics, types and stages of cancer, chemotherapy regimen, Hb at baseline, Hb level before each cycle of chemotherapy and treatment of anemia, were recorded.

STATISTICAL ANALYSIS

Patients' data were presented in terms of percent, mean or median. Logistic-regression analysis was performed to identify risk factors of anemia in cancer patients.

RESULTS

Three-hundred and four patients were enrolled, 233 patients were female and 71 were male. The age of patients varied from 15 to 86 years old. Median age was 52 years old. Hb level at enrollment ranged from 7.7 to 16.1 g/dl, mean baseline Hb was 12.5 g/dl. Incidence of anemia at baseline was 34.5 percent whereas the incidence increased to 61.1 percent after receiving chemotherapy. The incidence of anemia in all patients was not significantly different from that of a subgroup of patients with normal baseline Hb. The patients who received platinum and anthracycline-based chemotherapy developed more anemia than those who received other chemotherapy regimens, with odd ratios of 9.4 (95% CI; 3.1-28.9, p < 0.001) and 3.5 (95% CI; 1.4-8.5, p = 0.005), respectively. Most anemic patients were asymptomatic; twenty-one out of 214 anemic patients (9.8%) received specific treatment for anemia.

CONCLUSION

Chemotherapy-induced anemia is a common problem found in cancer patients, especially in those receiving platinum-based chemotherapy Most of the anemic patients had asymptomatic grade I and II anemia. Blood transfusion was the treatment of choice for severe, symptomatic anemia in our hospital.