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Gupta RK, Roy AM, Gupta A, Takabe K, Dhakal A, Opyrchal M, Kalinski P, Gandhi S. Systemic Therapy De-Escalation in Early-Stage Triple-Negative Breast Cancer: Dawn of a New Era? Cancers (Basel) 2022; 14:cancers14081856. [PMID: 35454764 PMCID: PMC9025008 DOI: 10.3390/cancers14081856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Triple-negative breast cancer is a life-threatening disease, even when identified at early stages. Recent advances have allowed the improvement of life expectancy via a personalized approach with the addition of newer chemotherapies, immunotherapies, and targeted therapies, but at the cost of added side effects. It has become increasingly clear that not all patients need such aggressive treatment. Here, we provide an overview of emerging opportunities to use less toxic therapies in patients at lower risk of recurrence or with mutations that can be effectively targeted using novel approaches. We provide a comprehensive review of completed and ongoing clinical trials with information on how to best stratify these patients for treatments to obtain maximum benefit without unnecessary toxicities. Abstract Early-stage triple negative breast cancer (TNBC) has been traditionally treated with surgery, radiation, and chemotherapy. The current standard of care systemic treatment of early-stage II and III TNBC involves the use of anthracycline-cyclophosphamide and carboplatin-paclitaxel with pembrolizumab in the neoadjuvant setting followed by adjuvant pembrolizumab per KEYNOTE-522. It is increasingly clear that not all patients with early-stage TNBC need this intensive treatment, thus paving the way for exploring opportunities for regimen de-escalation in selected subgroups. For T1a tumors (≤5 mm), chemotherapy is not used, and for tumors 6–10 mm (T1b) in size with negative lymph nodes, retrospective studies have failed to show a significant benefit with chemotherapy. In low-risk patients, anthracycline-free chemotherapy may be as effective as conventional therapy, as shown in some studies where replacing anthracyclines with carboplatin has shown non-inferior results for pathological complete response (pCR), which may form the backbone of future combination therapies. Recent advances in our understanding of TNBC heterogeneity, mutations, and surrogate markers of response such as pCR have enabled the development of multiple treatment options in the (neo)adjuvant setting in order to de-escalate treatment. These de-escalation studies based on tumor mutational status, such as using Poly ADP-ribose polymerase inhibitors (PARPi) in patients with BRCA mutations, and new immunotherapies such as PD1 blockade, have shown a promising impact on pCR. In addition, the investigational use of (bio)markers, such as high levels of tumor-infiltrating lymphocytes (TILs), low levels of tumor-associated macrophages (TAMs), and complete remission on imaging, also look promising. In this review, we cover the current standard of care systemic treatment of early TNBC and review the opportunities for treatment de-escalation based on clinical risk factors, biomarkers, mutational status, and molecular subtype.
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Affiliation(s)
- Ravi Kumar Gupta
- Department of Internal Medicine, Larkin Community Hospital, South Miami, FL 33143, USA;
| | - Arya Mariam Roy
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA; (A.M.R.); (A.G.); (P.K.)
| | - Ashish Gupta
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA; (A.M.R.); (A.G.); (P.K.)
| | - Kazuaki Takabe
- Department of Immunology and Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA;
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan
- Department of Surgery, Niigata University Graduate School of Medicine and Dental Sciences, Niigata 951-8510, Japan
- Department of Breast Surgery and Oncology, Tokyo Medical University, Tokyo 160-8402, Japan
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY 14263, USA
| | - Ajay Dhakal
- Department of Medicine, University of Rochester Medical Center, Rochester, NY 14648, USA;
| | - Mateusz Opyrchal
- Department of Medicine, Indiana University Simons Comprehensive Cancer Center, Indianapolis, IN 46202, USA;
| | - Pawel Kalinski
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA; (A.M.R.); (A.G.); (P.K.)
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Shipra Gandhi
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA; (A.M.R.); (A.G.); (P.K.)
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
- Correspondence: ; Tel.: +1-(716)-845-1686
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Rubio IT, Sobrido C. Neoadjuvant approach in patients with early breast cancer: patient assessment, staging, and planning. Breast 2022; 62 Suppl 1:S17-S24. [PMID: 34996668 PMCID: PMC9097809 DOI: 10.1016/j.breast.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 12/30/2021] [Indexed: 11/30/2022] Open
Abstract
Neoadjuvant treatment (NAT) has become an option in early stage (stage I-II) breast cancer (EBC). New advances in systemic and targeted therapies have increased rates of pathologic complete response increasing the number of patients undergoing NAT. Clear benefits of NAT are downstaging the tumor and the axillary nodes to de-escalate surgery and to evaluate response to treatment. Selection of patients for NAT in EBC rely in several factors that are related to patient characteristics (i.e, age and comorbidities), to tumor histology, to stage at diagnosis and to the potential changes in surgical or adjuvant treatments when NAT is administered. Imaging and histologic confirmation is performed to assess extent of disease y to confirm diagnosis. Besides mammogram and ultrasound, functional breast imaging MRI has been incorporated to better predict treatment response and residual disease. Contrast enhanced mammogram (CEM), shear wave elastography (SWE), or Dynamic Optical Breast Imaging (DOBI) are emerging techniques under investigation for assessment of response to neoadjuvant therapy as well as for predicting response. Surgical plan should be delineated after NAT taking into account baseline characteristics, tumor response and patient desire. In the COVID era, we have witnessed also the increasing use of NAT in patients who may be directed to surgery, unable to have it performed as surgery has been reserved for emergency cases only.
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Gandhi S, Brackstone M, Hong NJL, Grenier D, Donovan E, Lu FI, Skarpathiotakis M, Lee J, Boileau JF, Perera F, Simmons C, Joy AA, Tran WT, Tyono I, Van Massop A, Khalfan S. A Canadian national guideline on the neoadjuvant treatment of invasive breast cancer, including patient assessment, systemic therapy, and local management principles. Breast Cancer Res Treat 2022; 193:1-20. [PMID: 35224713 PMCID: PMC8993711 DOI: 10.1007/s10549-022-06522-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/16/2022] [Indexed: 12/11/2022]
Abstract
Purpose The neoadjuvant treatment of breast cancer (NABC) is a rapidly changing area that benefits from guidelines integrating evidence with expert consensus to help direct practice. This can optimize patient outcomes by ensuring the appropriate use of evolving neoadjuvant principles. Methods An expert panel formulated evidence-based practice recommendations spanning the entire neoadjuvant breast cancer treatment journey. These were sent for practice-based consensus across Canada using the modified Delphi methodology, through a secure online survey. Final recommendations were graded using the GRADE criteria for guidelines. The evidence was reviewed over the course of guideline development to ensure recommendations remained aligned with current relevant data. Results Response rate to the online survey was almost 30%; representation was achieved from various medical specialties from both community and academic centres in various Canadian provinces. Two rounds of consensus were required to achieve 80% or higher consensus on 59 final statements. Five additional statements were added to reflect updated evidence but not sent for consensus. Conclusions Key highlights of this comprehensive Canadian guideline on NABC include the use of neoadjuvant therapy for early stage triple negative and HER2 positive breast cancer, with subsequent adjuvant treatments for patients with residual disease. The use of molecular signatures, other targeted adjuvant therapies, and optimal response-based local regional management remain actively evolving areas. Many statements had evolving or limited data but still achieved high consensus, demonstrating the utility of such a guideline in helping to unify practice while further evidence evolves in this important area of breast cancer management.
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Chen Y, Hao S, Chen J, Huang X, Cao A, Hu Z, Liu G, Shao Z, Wu J. A Retrospective Cohort Study Comparing Traditional Breast Conservation With Oncoplastic Surgery in Breast Cancer Patients After Neoadjuvant Chemotherapy. Ann Plast Surg 2022; 88:144-151. [PMID: 34387578 DOI: 10.1097/sap.0000000000002971] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND To better understand the difference between traditional breast-conserving surgery (BCS) and oncoplastic surgery (OPS), we conducted a retrospective cohort study involving breast cancer patients who received neoadjuvant chemotherapy (NAC) and then underwent breast conservation at the Fudan University Shanghai Cancer Center. METHODS A retrospective chart review was conducted. All breast cancer patients who received NAC and then underwent traditional BCS or OPS at the Fudan University Shanghai Cancer Center from January 1, 2008, to December 31, 2019, were included. RESULTS Three hundred ninety-nine breast cancer patients received NAC and underwent traditional BCS, and 99 patients underwent OPS. The average age of the patients in the OPS group was younger than that in the BCS group (43 vs 48 years, P = 0.017). The size of the tumor assessed by ultrasonography at baseline in the OPS group was larger than that in the BCS group (31.3 vs 28.1 mm, P = 0.013). The same trend was observed in the clinical T stage and overall staging assessments before the administration of NAC in these 2 groups. Oncoplastic techniques were more frequently applied when tumors were located in areas with relatively few glands, such as the upper inner quadrant. There were no significant differences in the margins and distributions of pathological types and molecular subtypes between these 2 groups. The rates of pathological complete response were similar in the traditional BCS and OPS groups. CONCLUSIONS Unlike traditional BCS, in breast cancer patients after NAC, the adoption of oncoplastic techniques makes breast conservation feasible, even in patients with large tumors, late stages, and unfavorable tumor locations.
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Maheshwari R, Gadeval A, Raval N, Kalia K, Tekade RK. Laser activatable nanographene colloids for chemo-photothermal combined gene therapy of triple-negative breast cancer. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 133:112605. [PMID: 35525767 DOI: 10.1016/j.msec.2021.112605] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 12/01/2021] [Accepted: 12/07/2021] [Indexed: 11/16/2022]
Abstract
This investigation reports the green approach for developing laser activatable nanoscale-graphene colloids (nGC-CO-FA) for chemo-photothermal combined gene therapy of triple-negative breast cancer (TNBC). The nano colloid was found to be nanometric as characterized by SEM, AFM, and zeta sizer (68.2 ± 2.1 nm; 13.8 ± 1.2 mV). The doxorubicin (Dox) loaded employing hydrophobic interaction/π-π stacking showed >80% entrapment efficiency with a sustained pH-dependent drug release profile. It can efficiently incorporate siRNA and Dox and successfully co-localize them inside TNBC cells to obtain significant anticancer activity as evaluated using CCK-8 assay, apoptosis assay, cell cycle analysis, cellular uptake, fluorescence assay, endosomal escape study, DNA content analysis, and gene silencing efficacy studies. nGC-CO-FA/Dox/siRNA released the Dox in temperature- and a pH-responsive manner following NIR-808 laser irradiation. The synergistic photo-chemo-gene therapy using near infrared-808 nm laser (NIR-808) irradiation was found to be more effective as compared to without NIR-808 laser-treated counterparts (∆T: 37 ± 1.1 °C → to 49.2 ± 3.1 °C; 10 min; 0.5 W/cm2), suggesting the pivotal role of photothermal combined gene-therapy in the treatment of TNBC.
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Affiliation(s)
- Rahul Maheshwari
- National Institute of Pharmaceutical Education and Research-Ahmedabad (NIPER-A), An Institute of National Importance, Government of India, Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, Palaj, Opp. Air force station, Gandhinagar 382355, Gujarat, India
| | - Anuradha Gadeval
- National Institute of Pharmaceutical Education and Research-Ahmedabad (NIPER-A), An Institute of National Importance, Government of India, Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, Palaj, Opp. Air force station, Gandhinagar 382355, Gujarat, India
| | - Nidhi Raval
- National Institute of Pharmaceutical Education and Research-Ahmedabad (NIPER-A), An Institute of National Importance, Government of India, Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, Palaj, Opp. Air force station, Gandhinagar 382355, Gujarat, India
| | - Kiran Kalia
- National Institute of Pharmaceutical Education and Research-Ahmedabad (NIPER-A), An Institute of National Importance, Government of India, Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, Palaj, Opp. Air force station, Gandhinagar 382355, Gujarat, India
| | - Rakesh Kumar Tekade
- National Institute of Pharmaceutical Education and Research-Ahmedabad (NIPER-A), An Institute of National Importance, Government of India, Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, Palaj, Opp. Air force station, Gandhinagar 382355, Gujarat, India.
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Oncologic outcomes of immediate breast reconstruction in young women with breast cancer receiving neoadjuvant chemotherapy. Breast Cancer Res Treat 2021; 191:345-354. [PMID: 34718930 DOI: 10.1007/s10549-021-06428-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/14/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Oncologic safety of postmastectomy breast reconstruction in young women with breast cancer is not well-defined, especially in the setting of neoadjuvant chemotherapy (NACT). We retrospectively compared the oncologic outcomes following nipple-sparing (NSM)/skin-sparing mastectomy (SSM) with immediate breast reconstruction (IBR) and conventional mastectomy (CM) alone in young breast cancer patients after NACT. METHODS A total of 1266 women with primary breast cancer who underwent NACT followed by total mastectomy with or without IBR were reviewed. Of these, only young patients (age ≤ 40 years at diagnosis) were included in the outcome analysis (n = 375). After propensity score-matching by clinical T and N stage, molecular subtype, response to NACT, and adjuvant radiotherapy status, 228 patients were 1:1 matched, comprising balanced IBR group (with NSM/SSM) and CM-alone group. RESULTS The 5-year locoregional recurrence-free, disease-free, distant metastasis (DM)-free, and breast cancer-specific survival (BCSS) rates for the entire cohort of young patients were 83.4%, 65.3%, 71.7%, and 85.4%, respectively. Locoregional recurrence rates between the matched groups were similar (14% vs. 15.8%; p = 0.710); however, IBR group had significantly lower DM rate (27.2% vs. 40.4%; p = 0.036) and breast cancer mortality (14.9% vs. 27.2%; p = 0.023) than CM-alone group. IBR group showed significantly improved 5-year DM-free survival (74.1% vs. 62.6%; p = 0.043) and BCSS (89.1% vs. 77.6%; p = 0.048) rates than CM-alone group. CONCLUSIONS Our results indicated that IBR with NSM/SSM does not negatively affect long-term oncologic outcomes compared to CM alone in young women with breast cancer receiving NACT.
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Yang C, Zhang Z, Tang X, Zhang X, Chen Y, Hu T, Zhang H, Guan M, Zhang X, Wu Z. Pan-cancer analysis reveals homologous recombination deficiency score as a predictive marker for immunotherapy responders. Hum Cell 2021; 35:199-213. [PMID: 34628623 DOI: 10.1007/s13577-021-00630-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 10/02/2021] [Indexed: 02/07/2023]
Abstract
The immune context of the tumor microenvironment (TME) is critical for effective immunotherapy. Nonetheless, DNA-based biomarkers for the immune-sensitive TME and the identification of immune checkpoint inhibitor (ICI) responders are under-explored. This study aims to comprehensively landscape the homologous recombination deficiency (HRD) score, an emerging hallmark for tumor genome instability that triggers immune responsiveness across major cancer types, and to unveil their link to the TME and immunotherapeutic response. The HRD-associated genomic scars were characterized in 9088 tumor samples across 32 cancer types from TCGA. We evaluated the HRD score's performance in classifying ICI responders using an independent breast cancer cohort (GSE87049) and 11 in vivo murine mammary tumor models treated with anti-PD1/CTLA4 regimen (GSE124821). This study revealed a broad association between HRD-high genotype and neoantigenesis in the major cancer types including bladder cancer, breast cancer, head and neck squamous carcinoma, lung adenocarcinoma, lung squamous cell carcinoma, ovarian cancer, and sarcoma. Tumors with high HRD score bears increased leukocyte infiltration and lymphocyte fraction and demonstrated immune-sensitive microenvironment. The tumor immune dysfunction and exclusion (TIDE) model further confirmed HRD score-high genotype as a potential predictor for ICI immunotherapy responders in breast cancer. In conclusion, tumors with high HRD score exhibit an immune-sensitive TME. The HRD-high genotype is a promising marker for identifying ICI therapy responders among breast cancer patients.
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Affiliation(s)
- Can Yang
- Department of Laboratory Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Zijing Zhang
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Xuemei Tang
- Central Laboratory, Huashan Hospital North, Fudan University, Shanghai, 201907, China
| | - Xinju Zhang
- Central Laboratory, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Yuming Chen
- Department of Laboratory Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Tingting Hu
- Department of Laboratory Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Huating Zhang
- Department of Laboratory Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Ming Guan
- Department of Laboratory Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, China.
- Central Laboratory, Huashan Hospital North, Fudan University, Shanghai, 201907, China.
- Central Laboratory, Huashan Hospital, Fudan University, Shanghai, 200040, China.
- Clinical Laboratory, Huashan Hospital North, Fudan University, Shanghai, 201907, China.
| | - Xiuming Zhang
- Medical Laboratory, Shenzhen Luohu People's Hospital, Shenzhen, 518002, China.
| | - Zhiyuan Wu
- Department of Laboratory Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, China.
- Central Laboratory, Huashan Hospital North, Fudan University, Shanghai, 201907, China.
- Clinical Laboratory, Huashan Hospital North, Fudan University, Shanghai, 201907, China.
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Huynh V, Yang J, Bronsert M, Ludwigson A, Ahrendt G, Kim S, Matlock DD, Cohen J, Hampanda K, Tevis SE. Choosing Between Mastectomy and Breast-Conserving Therapy: Is Patient Distress an Influencing Factor? Ann Surg Oncol 2021; 28:8679-8687. [PMID: 34160707 DOI: 10.1245/s10434-021-10323-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/02/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Breast-conserving therapy (BCT) offers oncologic outcomes similar to those of mastectomy, yet many patients, when provided the option, choose mastectomy. This study aimed to evaluate the relationship between patient-reported distress and surgical decisions and to determine factors predictive of choosing BCT versus mastectomy. METHODS Patients with newly diagnosed breast cancer deemed candidates for BCT who completed a distress screen at their initial visit to an academic institution between 2016 and 2019 were retrospectively reviewed. This screening tool captures distress in emotional, social, health, and practical domains on a scale of 0 to 10. The distress scores were compared against surgical decisions using nonparametric Wilcoxon rank-sum tests. Patient factors associated with surgical choice were analyzed using chi-square, Fisher's exact, and Student's t tests. A two-sided p value lower than 0.05 was considered significant. RESULTS Of 506 patients deemed eligible for BCT, 430 (85%) chose BCT and 76 (15%) pursued mastectomy. The distress levels did not differ significantly between the surgical options. The patients who underwent mastectomy were on the average younger (50.7 vs 60.4 years; p < 0.0001), presented with palpable masses (p < 0.0001), had stage 0, 2, or 3 versus stage 1 disease (p < 0.0001), sought consultation for second opinions (19.7% vs 8.6%; p = 0.0032), received neoadjuvant chemotherapy (31.6% vs 16.3%; p = 0.0016), or had deleterious gene mutations (21.1% vs 5.1%; p < 0.0001). CONCLUSIONS Distress was not associated with the pursuit of surgical treatment. Rather, younger age, search for a second opinion, and a palpable mass present at presentation were associated with more aggressive surgical decisions. Understanding factors that influence surgical decision-making is critical in guiding informed decisions that reflect patient values.
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Affiliation(s)
- Victoria Huynh
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jerry Yang
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael Bronsert
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Aurora, CO, USA
| | | | - Gretchen Ahrendt
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Simon Kim
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Daniel D Matlock
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Justin Cohen
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Karen Hampanda
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sarah E Tevis
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
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Hyder T, Bhattacharya S, Gade K, Nasrazadani A, Brufsky AM. Approaching Neoadjuvant Therapy in the Management of Early-Stage Breast Cancer. BREAST CANCER (DOVE MEDICAL PRESS) 2021; 13:199-211. [PMID: 33833568 PMCID: PMC8019614 DOI: 10.2147/bctt.s273058] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 03/19/2021] [Indexed: 12/11/2022]
Abstract
Neoadjuvant therapy is integral to the treatment of early-stage breast cancer. Goals of treatment include surgical downstaging of the tumor, rendering inoperable tumors resectable, and de-escalating axillary surgery in those with clinically positive nodes. Additionally, response to treatment provides important prognostic information regarding risk of recurrence and guides future adjuvant treatment. Although chemotherapy serves as the backbone of neoadjuvant treatment, an increased understanding of the tumor's clinical course as well as its molecular and genetic make-up aids in individualizing treatment and developing novel agents. This review summarizes current clinical approaches and the future direction to the management of breast cancer patients in the neoadjuvant setting.
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Affiliation(s)
- Tara Hyder
- University of Pittsburgh Physicians, Pittsburgh, PA, USA
| | - Saveri Bhattacharya
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kristine Gade
- UPMC Hillman Cancer Center, Magee Women’s Hospital, Pittsburgh, PA, USA
| | | | - Adam M Brufsky
- UPMC Hillman Cancer Center, Magee Women’s Hospital, Pittsburgh, PA, USA
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Wu ZY, Kim GB, Lee S, Choi SH, Kim N, Ko B. Case Report: A 3D-Printed Surgical Guide for Breast-Conserving Surgery After Neoadjuvant Chemotherapy. Front Oncol 2021; 11:633302. [PMID: 33842340 PMCID: PMC8027348 DOI: 10.3389/fonc.2021.633302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background A challenging problem for patients undergoing breast-conserving surgery after neoadjuvant chemotherapy (NACT) is the accuracy of preoperative tumor localization. After chemotherapy, the original tumor is likely to shrink or scatter dramatically or even show complete remission. For breast-conserving surgery, the development of a guidance device to accurately estimate the resection area is imperative. Case Presentation We produced a three-dimensional (3D)-printed breast surgical guide (BSG) based on prone and supine magnetic resonance imaging (MRI). This device was tested on a patient who underwent breast-conserving surgery after NACT. Both ultrasonography and MRI revealed that the tumor shrank substantially after NACT. Identifying the target tumor area using pre-NACT MRI was feasible, and the tumor was safely removed with clear resection margins. Conclusion The BSG has several advantages over conventional methods for tumor localization after NACT. In particular, the BSG provided precise quantitative MRI information about the tumor area.
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Affiliation(s)
- Zhen-Yu Wu
- Department of Breast Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China.,Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.,Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, South Korea
| | - Guk Bae Kim
- Research Department, Anymedi Inc., Seoul, South Korea
| | - Sangwook Lee
- Research Department, Anymedi Inc., Seoul, South Korea
| | | | - Namkug Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - BeomSeok Ko
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Cen C, Chun J, Kaplowitz E, Axelrod D, Shapiro R, Guth A, Schnabel F. Margin Assessment and Re-excision Rates for Patients Who Have Neoadjuvant Chemotherapy and Breast-Conserving Surgery. Ann Surg Oncol 2021; 28:5142-5148. [PMID: 33635409 DOI: 10.1245/s10434-020-09524-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/10/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) has enabled more patients to be eligible for breast-conservation surgery (BCS). Achieving negative lumpectomy margins, however, is challenging due to changes in tissue composition and potentially scattered residual carcinoma in the tumor bed. Data regarding BCS after NAC have shown variable re-excision rates. MarginProbe (Dilon Technologies, Newport News, VA, USA) has been shown to identify positive resection margins intraoperatively and to reduce the number of re-excisions in primary BCS, but has not been studied in NAC+BCS cases. This study aimed to investigate the clinicopathologic characteristics, margin status, and re-excision rates for NAC+BCS patients with and without the use of MarginProbe. METHODS The Institutional Breast Cancer Database was queried for patients who received NAC and had BCS from 2010 to 2019. The variables of interest were demographics, tumor characteristics, pathologic complete response (pCR), MarginProbe use, and re-excision rates. RESULTS The study population consisted of 214 patients who had NAC, 61 (28.5 %) of whom had NAC+BCS. The median age of the patients was 53.5 years. A pCR was achieved for 19 of the patients (31.1 %). Of the remaining 42 patients, 9 (21 %) had close or positive margins that required re-excision. Re-excision was associated with a larger residual tumor size (p = 0.025) and estrogen receptor (ER)-positive disease before NAC (p = 0.041). MarginProbe use was associated with a lower re-excision rate for the patients who had NAC+BCS (6 % vs. 31 %, respectively). CONCLUSION The patients with a larger residual tumor burden and ER-positive disease had a greater risk for inadequate margins at surgery. MarginProbe use was associated with a lower re-excision rate. Techniques to reduce the need for re-excision will support the use of BCS after NAC.
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Affiliation(s)
- Cindy Cen
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Jennifer Chun
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Elianna Kaplowitz
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Deborah Axelrod
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Richard Shapiro
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Amber Guth
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Freya Schnabel
- Department of Surgery, New York University Langone Health, New York, NY, USA.
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Wu ZY, Kim GB, Choi S, Lee S, Kim N, Ko B. Breast-Conserving Surgery after Neoadjuvant Chemotherapy Using a Three-Dimensional-Printed Surgical Guide Based on Supine Magnetic Resonance Imaging: A Case Report. J Breast Cancer 2021; 24:235-240. [PMID: 33818018 PMCID: PMC8090799 DOI: 10.4048/jbc.2021.24.e8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/01/2021] [Accepted: 01/04/2021] [Indexed: 11/30/2022] Open
Abstract
Tumor localization in patients receiving neoadjuvant chemotherapy (NACT) is challenging because substantial therapeutic remission of the original tumor after NACT is often noted. Currently, there is no guidance device that allows for an accurate estimation of the resection range in breast-conserving surgery after NACT. To increase the accuracy of tumor resection, we used a 3-dimensional-printed breast surgical guide based on magnetic resonance imaging (MRI) in the supine position for a breast cancer patient who underwent breast-conserving surgery after NACT. Using this device, the breast tumor with apparent therapeutic changes after NACT on imaging was successfully removed with clear resection margins by identifying the original tumor site in the affected breast. Irrespective of whether the residual tumor area after NACT is well defined, it is possible to confirm and target the tumor area on pre-NACT MRI using this device.
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Affiliation(s)
- Zhen Yu Wu
- Department of Breast Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China.,Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | | | | | | | - Namkug Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - BeomSeok Ko
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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63
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Untch M. Local and regional therapy considerations after preoperative therapy in patients with breast cancer. Curr Opin Obstet Gynecol 2021; 33:59-63. [PMID: 33122576 DOI: 10.1097/gco.0000000000000672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The starting point of neoadjuvant therapy was to use preoperative chemotherapy in order to provide surgeons and radiotherapists with the possibility of local treatment in patients with locally advanced, primary inoperable or inflammatory disease. Since then, this treatment approach has dramatically evolved and is now a standard of care in patients with high-risk early breast cancer. RECENT FINDINGS The role of surgery after neoadjuvant therapy is to remove residual disease in the breast and or in the lymph nodes and to provide further treatment possibilities according to pathohistologic findings at surgery. SUMMARY Innovative medical treatments are now being used for neoadjuvant treatment in order to reduce the extent of locoregional surgery in the breast and the axilla and also to adjust further medical treatment after neoadjuvant therapy and surgery.
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Affiliation(s)
- Michael Untch
- Helios Klinikum Berlin-Buch, Germany, Clinic for Gynecology, Gynecologic Oncology and Obstetrics, Berlin, Germany
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64
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Korde LA, Somerfield MR, Carey LA, Crews JR, Denduluri N, Hwang ES, Khan SA, Loibl S, Morris EA, Perez A, Regan MM, Spears PA, Sudheendra PK, Symmans WF, Yung RL, Harvey BE, Hershman DL. Neoadjuvant Chemotherapy, Endocrine Therapy, and Targeted Therapy for Breast Cancer: ASCO Guideline. J Clin Oncol 2021; 39:1485-1505. [PMID: 33507815 DOI: 10.1200/jco.20.03399] [Citation(s) in RCA: 375] [Impact Index Per Article: 125.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To develop guideline recommendations concerning optimal neoadjuvant therapy for breast cancer. METHODS ASCO convened an Expert Panel to conduct a systematic review of the literature on neoadjuvant therapy for breast cancer and provide recommended care options. RESULTS A total of 41 articles met eligibility criteria and form the evidentiary basis for the guideline recommendations. RECOMMENDATIONS Patients undergoing neoadjuvant therapy should be managed by a multidisciplinary care team. Appropriate candidates for neoadjuvant therapy include patients with inflammatory breast cancer and those in whom residual disease may prompt a change in therapy. Neoadjuvant therapy can also be used to reduce the extent of local therapy or reduce delays in initiating therapy. Although tumor histology, grade, stage, and estrogen, progesterone, and human epidermal growth factor receptor 2 (HER2) expression should routinely be used to guide clinical decisions, there is insufficient evidence to support the use of other markers or genomic profiles. Patients with triple-negative breast cancer (TNBC) who have clinically node-positive and/or at least T1c disease should be offered an anthracycline- and taxane-containing regimen; those with cT1a or cT1bN0 TNBC should not routinely be offered neoadjuvant therapy. Carboplatin may be offered to patients with TNBC to increase pathologic complete response. There is currently insufficient evidence to support adding immune checkpoint inhibitors to standard chemotherapy. In patients with hormone receptor (HR)-positive (HR-positive), HER2-negative tumors, neoadjuvant chemotherapy can be used when a treatment decision can be made without surgical information. Among postmenopausal patients with HR-positive, HER2-negative disease, hormone therapy can be used to downstage disease. Patients with node-positive or high-risk node-negative, HER2-positive disease should be offered neoadjuvant therapy in combination with anti-HER2-positive therapy. Patients with T1aN0 and T1bN0, HER2-positive disease should not be routinely offered neoadjuvant therapy.Additional information is available at www.asco.org/breast-cancer-guidelines.
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Affiliation(s)
- Larissa A Korde
- Clinical Investigations Branch, CTEP, DCTD, National Cancer Institute, Bethesda, MD
| | | | - Lisa A Carey
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | | | | | | | | | | | | | - Alejandra Perez
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Plantation, FL
| | | | - Patricia A Spears
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | | | | | | | | | - Dawn L Hershman
- Herbert Irving Comprehensive Cancer Center at Columbia University, New York, NY
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65
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Dubsky P, Pinker K, Cardoso F, Montagna G, Ritter M, Denkert C, Rubio IT, de Azambuja E, Curigliano G, Gentilini O, Gnant M, Günthert A, Hauser N, Heil J, Knauer M, Knotek-Roggenbauerc M, Knox S, Kovacs T, Kuerer HM, Loibl S, Mannhart M, Meattini I, Penault-Llorca F, Radosevic-Robin N, Sager P, Španić T, Steyerova P, Tausch C, Peeters MJTFDV, Weber WP, Cardoso MJ, Poortmans P. Breast conservation and axillary management after primary systemic therapy in patients with early-stage breast cancer: the Lucerne toolbox. Lancet Oncol 2021; 22:e18-e28. [PMID: 33387500 DOI: 10.1016/s1470-2045(20)30580-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/26/2020] [Accepted: 09/07/2020] [Indexed: 12/13/2022]
Abstract
Primary systemic therapy is increasingly used in the treatment of patients with early-stage breast cancer, but few guidelines specifically address optimal locoregional therapies. Therefore, we established an international consortium to discuss clinical evidence and to provide expert advice on technical management of patients with early-stage breast cancer. The steering committee prepared six working packages to address all major clinical questions from diagnosis to surgery. During a consensus meeting that included members from European scientific oncology societies, clinical trial groups, and patient advocates, statements were discussed and voted on. A consensus was reached in 42% of statements, a majority in 38%, and no decision in 21%. Based on these findings, the panel developed clinical guidance recommendations and a toolbox to overcome many clinical and technical requirements associated with the diagnosis, response assessment, surgical planning, and surgery of patients with early-stage breast cancer. This guidance could convince clinicians and patients of the major clinical advancements purported by primary systemic therapy, the use of less extensive and more targeted surgery to improve the lives of patients with breast cancer.
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Affiliation(s)
- Peter Dubsky
- Breast Centre, Hirslanden Klinik St Anna, Luzern, Switzerland; Department of Surgery, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
| | - Katja Pinker
- Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Gender Imaging, Medical University of Vienna, Vienna, Austria; Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center and Foundation, Lisbon, Portugal
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Breast Center, University Hospital Basel, Basel, Switzerland
| | - Mathilde Ritter
- Breast Center, University Hospital Basel, Basel, Switzerland
| | - Carsten Denkert
- Institute of Pathology, Philipps-University Marburg and University Hospital Marburg, Marburg, Germany
| | - Isabel T Rubio
- Breast Surgical Oncology Unit, Clinica Universidad de Navarra, Universidad de Navarra, Madrid, Spain
| | - Evandro de Azambuja
- Institut Jules Bordet, Brussels, Belgium; l'Université Libre de Bruxelles, Brussels, Belgium
| | | | - Oreste Gentilini
- Breast Surgery, San Raffaele University and Research Hospital, Milan, Italy
| | - Michael Gnant
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Andreas Günthert
- Breast Centre, Hirslanden Klinik St Anna, Luzern, Switzerland; Department of Breast Surgery, Gyn-zentrum Luzern, Luzern, Switzerland
| | - Nik Hauser
- Breast Centre Aarau Cham Zug, Hirslanden Klinik, Aarau, Switzerland; Frauenarztzentrum Aargau Ag, Baden, Switzerland
| | - Joerg Heil
- Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Knauer
- Breast Center Eastern Switzerland, St Gallen, Switzerland
| | | | - Susan Knox
- Europa Donna-The European Breast Cancer Coalition, Milan, Italy
| | - Tibor Kovacs
- Department of Breast Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK; Breast Institute, Jiahui International Hospital, Shanghai, China
| | - Henry M Kuerer
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sibylle Loibl
- German Breast Group, Neu-Isenburg, Germany; Centre for Haematology and Oncology Bethanien, Frankfurt, Germany
| | - Meinrad Mannhart
- Breast Centre Aarau Cham Zug, Hirslanden Klinik, Aarau, Switzerland
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Frederique Penault-Llorca
- Department of Pathology and Biopathology, Jean Perrin Comprehensive Cancer Centre, University Clermont Auvergne, INSERM U1240 IMoST, Clermont-Ferrand, France
| | - Nina Radosevic-Robin
- Department of Pathology and Biopathology, Jean Perrin Comprehensive Cancer Centre, University Clermont Auvergne, INSERM U1240 IMoST, Clermont-Ferrand, France
| | | | - Tanja Španić
- Europa Donna-The European Breast Cancer Coalition, Milan, Italy
| | - Petra Steyerova
- Breast Cancer Screening and Diagnostic Center, Clinic of Radiology, General University Hospital in Prague, Prague, Czech Republic
| | | | | | - Walter P Weber
- Breast Center, University Hospital Basel, Basel, Switzerland; Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Maria J Cardoso
- Breast Unit, Champalimaud Clinical Center and Foundation, Lisbon, Portugal; Nova Medical School, Lisbon, Portugal
| | - Philip Poortmans
- Iridium Kankernetwerk, Wilrijk-Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk-Antwerp, Belgium
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66
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Rocco N, Catanuto G, Chiodini P, Rispoli C, Nava MB. Implants versus autologous tissue flaps for breast reconstruction following mastectomy. Hippokratia 2021. [DOI: 10.1002/14651858.cd013821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Nicola Rocco
- G.Re.T.A. Group for Reconstructive and Therapeutic Advancements; Naples Italy
| | - Giuseppe Catanuto
- Multidisciplinary Breast Unit; Azienda Ospedaliera Cannizzaro; Catania Italy
- G.Re.T.A. Group for Reconstructive and Therapeutic Advancements; Catania Italy
| | - Paolo Chiodini
- Physical and Mental Health; University of Campania "Luigi Vanvitelli"; Napoli Italy
| | | | - Maurizio B Nava
- G.Re.T.A. Group for Reconstructive and Therapeutic Advancements; Milan Italy
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67
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Song D, Man X, Jin M, Li Q, Wang H, Du Y. A Decision-Making Supporting Prediction Method for Breast Cancer Neoadjuvant Chemotherapy. Front Oncol 2021; 10:592556. [PMID: 33469514 PMCID: PMC7813988 DOI: 10.3389/fonc.2020.592556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/16/2020] [Indexed: 01/02/2023] Open
Abstract
Neoadjuvant chemotherapy (NAC) may increase the resection rate of breast cancer and shows promising effects on patient prognosis. It has become a necessary treatment choice and is widely used in the clinical setting. Benefitting from the clinical information obtained during NAC treatment, computational methods can improve decision-making by evaluating and predicting treatment responses using a multidisciplinary approach, as there are no uniformly accepted protocols for all institutions for adopting different treatment regiments. In this study, 166 Chinese breast cancer cases were collected from patients who received NAC treatment at the First Bethune Hospital of Jilin University. The Miller–Payne grading system was used to evaluate the treatment response. Four machine learning multiple classifiers were constructed to predict the treatment response against the 26 features extracted from the patients’ clinical data, including Random Forest (RF) model, Convolution Neural Network (CNN) model, Support Vector Machine (SVM) model, and Logistic Regression (LR) model, where the RF model achieved the best performance using our data. To allow a more general application, the models were reconstructed using only six selected features, and the RF model achieved the highest performance with 54.26% accuracy. This work can efficiently guide optimal treatment planning for breast cancer patients.
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Affiliation(s)
- Dong Song
- Department of Breast Surgery, The First Hospital, Jilin University, Changchun, China
| | - Xiaxia Man
- Department of Oncological Gynecology, The First Hospital, Jilin University, Changchun, China
| | - Meng Jin
- School of Information Science and Technology, Northeast Normal University, Changchun, China.,Institute of Computational Biology, Northeast Normal University, Changchun, China
| | - Qian Li
- Department of Breast Surgery, The First Hospital, Jilin University, Changchun, China
| | - Han Wang
- School of Information Science and Technology, Northeast Normal University, Changchun, China.,Institute of Computational Biology, Northeast Normal University, Changchun, China
| | - Ye Du
- Department of Breast Surgery, The First Hospital, Jilin University, Changchun, China
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68
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Abstract
ABSTRACT Triple-negative breast cancer, compared with other molecular subtypes, poses particular challenges for optimizing the timing and the extent of locoregional treatments. In the past, the combination of increased rates of both locoregional and distant recurrences led to a preference of radical surgery and extensive radiation therapy; however, since the introduction of more effective chemotherapy, a sharp de-escalation in the extent of locoregional treatments followed. Current evidence confirms that less aggressive surgery in combination with tailored radiation therapy offers improved oncological outcomes combined with better quality of life. However, further research is required to optimize locoregional treatments, considering the significant heterogeneity in biological behavior and tumor response to systemic treatments.
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69
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Yamaguchi T, Hozumi Y, Sagara Y, Takahashi M, Yoneyama K, Fujisawa T, Osumi S, Akabane H, Nishimura R, Mieno MN, Mukai H. The impact of neoadjuvant systemic therapy on breast conservation rates in patients with HER2-positive breast cancer: Surgical results from a phase II randomized controlled trial. Surg Oncol 2020; 36:51-55. [PMID: 33310293 DOI: 10.1016/j.suronc.2020.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 11/04/2020] [Accepted: 11/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Neoadjuvant systemic therapy (NST) induces tumor shrinkage and boosts the chance of breast-conserving thearpy (BCT) in patients with breast cancer. However, only a few trials have evaluated the effect of NST in conversion from BCT ineligibility to BCT eligibility in HER2-positive breast cancer. METHODS We conducted the surgical sub-study of a phase II randomized trial, which compared standard neoadjuvant treatment or an experimental treatment modified according to the interim Ki-67 evaluation in women with stage II or III HER2-positive breast cancer. The treating surgeons assessed eligibility for BCT before and after NST. We evaluated the change in BCT eligibility following NST. We also analyzed the type of surgery performed and the success rate of BCT. RESULTS Two hundred six patients were included in this study. Of these, 44.0% were considered BCT candidates at baseline, while 69.8% were deemed eligible for BCT after NST (P < 0.001). Among non-BCT candidates at baseline, 46% successfully converted to BCT candidates. Of 139 patients deemed eligible for BCT following NST, 84.2% attempted BCT, and successful BCT, defined as tumor-free at all surgical margins, was achieved in 96.8% of patients. Different treatment arms did not affect the rate of post-NST BCT eligibility (70.0% vs 69.7%). CONCLUSIONS This study demonstrated that NST resulted in an absolute increase of 25.8% in the rate of BCT eligibility in HER2-positive breast cancer. About a half of non-BCT candidates converted to BCT candidates. BCT was successful in most patients who attempted BCT. There were still patients who chose mastectomy even though they were deemed eligible for BCT. Patients considered BCT-ineligible due to large tumor size most likely converted to BCT-eligible with NST. On the other hand, NST had less impact on the surgical indication of patients with multicentric disease or probable poor cosmetic outcome.
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Affiliation(s)
- Takeshi Yamaguchi
- Medical Oncology, Japanese Red Cross Musashino Hospital. 1-26-1 Kyonan-cho, Musashino-shi, Tokyo, 180-8610, Japan.
| | - Yasuo Hozumi
- Breast and Endocrine Surgery, University of Tsukuba Hospital/ Ibaraki Prefectural Central Hospital. 6528 Koibuchi, Kasama City, Ibaraki, 309-1793, Japan.
| | - Yasuaki Sagara
- Breast Oncology, Sagara Hospital, Hakuaikai Medical Corporation, 3-31 Matsubara-cho, Kagoshima-shi, Kagoshima, 343-0832, Japan.
| | - Masato Takahashi
- Breast Surgery, NHO Hokkaido Cancer Center, 4-2 Kikusui, Shiroishi-ku, Sapporo, Hokkaido, 003-0804, Japan.
| | - Kimiyasu Yoneyama
- Breast Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Tomomi Fujisawa
- Breast Oncology, Gunma Prefectural Cancer Center, 617-1 Takahayashinishi-cho, Ota-shi, Gunma, 373-8550, Japan.
| | - Shozo Osumi
- Breast Oncology, Shikoku Cancer Center, 160 Kou, Minamiumemoto-cho, Matsuyama, Ehime, 791-0280, Japan.
| | - Hiromitsu Akabane
- Breast Surgery, Asahikawa Kosei Hospital, 24-111, Ichi-jodori, Asahikawa-shi, Hokkaido, 078-8211, Japan
| | - Reiki Nishimura
- Breast Surgery, Kumamoto Shinto General Hospital, 3-2-65 Oe, Chuo-ku, Kumamoto-shi, Kumamoto, 862-8655, Japan.
| | - Makiko Naka Mieno
- Department of Medical Informatics, Center for Information, Jichi Medical University. 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Hirofumi Mukai
- Breast and Medical Oncology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
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70
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Esgueva A, Siso C, Espinosa-Bravo M, Sobrido C, Miranda I, Salazar JP, Rubio IT. Leveraging the increased rates of pathologic complete response after neoadjuvant treatment in breast cancer to de-escalate surgical treatments. J Surg Oncol 2020; 123:71-79. [PMID: 33002230 DOI: 10.1002/jso.26236] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/05/2020] [Accepted: 09/14/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Breast conservative surgery (BCS) and sentinel lymph node biopsy (SLNB) after neoadjuvant treatment (NAT) is safe and effective for selected patients. This aim of this study is to evaluate the impact of anatomic site of response on outcomes and to assess the real population who may benefit from nonsurgical approaches after NAT. MATERIAL AND METHODS From a prospectively maintained database, patients with T1-4 N0-2 breast cancer undergoing NAT were identified. Clinicopathological and survival rates were compared in relation to response and anatomic site of response. RESULTS Six hundred and forty-six patients were included in the study. Pathologic complete response (pCR) was an independent factor for BCS and SLN. HER2 positive and TN tumors with cN0 achieving a breast pCR remain ypN0 (p = .002). Residual axillary disease was associated with breast residual tumor (p = .05) and subtype (p = .001). With a median follow up of 35.25 months, patients with any pCR had improved survival when compared with partial response, but not significant differences between pCR, axillary pCR, or breast pCR. CONCLUSION Achieving a pCR increases BCS and SLN. In selected subgroups, sparing any axillary surgery after NAT maybe feasible. In cN+ patients, any pCR was associated with survival, but not the anatomic site of response.
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Affiliation(s)
- Antonio Esgueva
- Department of Breast Surgical Oncology, Clinica Universidad de Navarra, Universidad de Navarra, Madrid, Spain
| | - Christian Siso
- Department of Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Martin Espinosa-Bravo
- Department of Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Carolina Sobrido
- Breast Imaging Unit, Department of Radiology, Clinica Universidad de Navarra, Universidad de Navarra, Madrid, Spain
| | - Ignacio Miranda
- Breast Imaging Unit, Department of Radiology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Juan P Salazar
- Breast Imaging Unit, Department of Radiology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Isabel T Rubio
- Department of Breast Surgical Oncology, Clinica Universidad de Navarra, Universidad de Navarra, Madrid, Spain
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71
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Ponzone R, Montemurro F. Extent of Breast Surgery After Neoadjuvant Chemotherapy for Triple-Negative Breast Cancer. JAMA Surg 2020; 155:785-786. [PMID: 32401290 DOI: 10.1001/jamasurg.2020.1021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Riccardo Ponzone
- Gynecological Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Filippo Montemurro
- Multidisciplinary Oncology Outpatient Clinic, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
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72
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Benson JR, Dumitru D. Extent of Breast Surgery After Neoadjuvant Chemotherapy for Triple-Negative Breast Cancer. JAMA Surg 2020; 155:784-785. [PMID: 32401292 DOI: 10.1001/jamasurg.2020.1001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- John R Benson
- Addenbrooke's Hospital, Anglia Ruskin School of Medicine, Cambridge, England
| | - Dorin Dumitru
- Hull University Teaching Hospitals National Health Services Trust, Hull-York Medical School, Hull, England
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73
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Phillips BT, Brown S, Ha AY, Janes LE, Malik M, Massand S, Ramly EP, Saha S, Serebrakian AT, Tumkur D, Gosain AK. Spotlight in Plastic Surgery: July 2020. Plast Reconstr Surg 2020; 146:209-212. [DOI: 10.1097/prs.0000000000006972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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74
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Petruolo O, Sevilimedu V, Montagna G, Le T, Morrow M, Barrio AV. How Often Does Modern Neoadjuvant Chemotherapy Downstage Patients to Breast-Conserving Surgery? Ann Surg Oncol 2020; 28:287-294. [PMID: 32514804 DOI: 10.1245/s10434-020-08593-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) has been proven to increase breast-conserving surgery (BCS) rates, but data are limited on conversion rates from BCS-ineligible (BCSi) to BCS-eligible (BCSe), specifically, in patients with large tumors. METHODS Consecutive patients with stage I-III breast cancer treated with NAC from November 2013 to March 2019 were identified. BCS eligibility before and after NAC was prospectively determined. Patients deemed BCSi before NAC due to large tumor size were studied. Statistical analyses were conducted using Student's t-test, Wilcoxon rank sum test, Chi-square test, Fisher's test, and logistic regression. RESULTS In this study, 600 of 1353 cancers were BCSi with large tumors; 69% were non-BCS candidates, 31% were borderline-BCS (bBCS) candidates. Of non-BCS candidates, 69% became BCSe after NAC; 66% chose BCS, and 90% were successful. Among bBCS candidates, 87% were BCSe after NAC, 73% chose BCS, and 96% were successful. On univariate analysis, bBCS candidacy, lower cT stage, cN0 status, absence of calcifications, human epidermal growth factor receptor 2 positive (HER2+)/triple negative (TN) receptor status, poor differentiation, ductal histology, and breast pCR were associated with conversion to BCS eligibility. On multivariable analysis, receptor status (hormone receptor positive [HR+]/HER2- ref; odds ratio [OR] HER2+ 1.63, P = 0.047; HR-/HER2- OR, 2.26, P = 0.003) and breast pCR (OR 2.62, P < 0.001) predicted successful downstaging, while larger clinical tumor size (OR 0.86, P = 0.003), non-BCS candidacy (OR 0.46, P = 0.003), cN+ status (OR 0.54, P = 0.008), and calcifications (OR 0.56, P = 0.007) predicted lower downstaging rates. CONCLUSION In patients with large tumors precluding BCS, conversion to BCS eligibility was high with NAC, particularly in bBCS candidates. HER2+/TN receptor status predicted successful downstaging, while lower downstaging rates were observed with larger tumors, cN+ status, and calcifications. These factors should be considered when selecting patients for NAC.
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Affiliation(s)
- Oriana Petruolo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tiana Le
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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75
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Rational Cancer Treatment Combinations: An Urgent Clinical Need. Mol Cell 2020; 78:1002-1018. [DOI: 10.1016/j.molcel.2020.05.031] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 02/07/2023]
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Gonçalves A, Bertucci A, Bertucci F. PARP Inhibitors in the Treatment of Early Breast Cancer: The Step Beyond? Cancers (Basel) 2020; 12:cancers12061378. [PMID: 32471249 PMCID: PMC7352970 DOI: 10.3390/cancers12061378] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023] Open
Abstract
Exquisitely exploiting defects in homologous recombination process, poly(ADP-ribose) polymerase (PARP) inhibitors have recently emerged as a promising class of therapeutics in human epidermal growth factor receptor 2 (HER2)-negative advanced breast cancer with germline breast cancer 1 (BRCA1) or breast cancer 2 (BRCA2) mutations (gBRCA1/2m). In this setting, PARP inhibitors, either as single agent or in combination with platinum-based chemotherapy, significantly increased progression-free survival, as compared to conventional chemotherapy. Accordingly, further therapeutic advances are expected at an earlier stage of the disease. In the neoadjuvant setting, veliparib failed to increase the pathological complete response rate when added to a carboplatin-based regimen, in unselected triple-negative breast cancer patients. Similarly, when administered before anthracycline-cyclophosphamide, the neoadjuvant olaparib-paclitaxel combination was not superior to carboplatin–paclitaxel, in patients with HER2-negative breast cancer and BRCA1/2 mutation, or homologous recombination defect. Yet, neoadjuvant talazoparib, administered as a single-agent in patients with HER2-negative breast cancer and germline BRCA1/2 mutation, achieved an impressive pathological complete response rate of nearly 50%. In the adjuvant setting, the results from the OlympiA phase III study, evaluating adjuvant olaparib in HER2-negative early breast cancer and germline BRCA1/2 mutations, are eagerly awaited. Ongoing trials should clarify whether PARP inhibitors might improve outcome when administered in the adjuvant or neoadjuvant setting in early breast cancer patients with BRCA1/2 mutation or homologous recombination defect.
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Affiliation(s)
- Anthony Gonçalves
- Medical Oncology Department, Cancer Research Center of Marseille (CRCM), INSERM U1068, CNRS UMR7258, Institut Paoli-Calmettes, Aix-Marseille University, 13009 Marseille, France; (A.B.); (F.B.)
- Predictive Oncology Laboratory, Cancer Research Center of Marseille (CRCM), Inserm U1068, CNRS UMR7258, Aix-Marseille University, 13009 Marseille, France
- Correspondence: ; Tel.: +33-4-91-22-37-89; Fax: +33-4-91-22-36-70
| | - Alexandre Bertucci
- Medical Oncology Department, Cancer Research Center of Marseille (CRCM), INSERM U1068, CNRS UMR7258, Institut Paoli-Calmettes, Aix-Marseille University, 13009 Marseille, France; (A.B.); (F.B.)
| | - François Bertucci
- Medical Oncology Department, Cancer Research Center of Marseille (CRCM), INSERM U1068, CNRS UMR7258, Institut Paoli-Calmettes, Aix-Marseille University, 13009 Marseille, France; (A.B.); (F.B.)
- Predictive Oncology Laboratory, Cancer Research Center of Marseille (CRCM), Inserm U1068, CNRS UMR7258, Aix-Marseille University, 13009 Marseille, France
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Is breast conserving therapy better than mastectomy? Surgeons must speak out. Eur J Surg Oncol 2020; 46:1551-1553. [PMID: 32439264 DOI: 10.1016/j.ejso.2020.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/01/2020] [Accepted: 05/08/2020] [Indexed: 11/23/2022] Open
Abstract
Several population-based studies suggest that breast conserving surgery followed by radiotherapy (BCT) may provide longer overall survival than mastectomy. Better locoregional control after BCT due to improvements of preoperative imaging, oncoplastic surgery and radiotherapy, as well as the recent trend towards surgical de-escalation may be involved. Alternatively, modern radiotherapy may have such an improved benefit/risk ratio that its survival advantage now stands out more clearly. However, since the therapeutic equivalence of BCT and mastectomy was demonstrated by several randomised trials, this information cannot be disregarded, nor radiotherapy should be used to compensate for inadequate surgery. Both BCT and mastectomy are likely here to stay as clinical presentation of breast cancer is highly variable, and women desires may transcend a rational balance of pros and cons between the two surgical approaches. Our duty as surgeons is to lead the multidisciplinary board and accompany the patients along this difficult decision-making process.
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