Phase II study of preoperative sequential FEC and docetaxel predicts of pathological response and disease free survival

A case of synchronous bilateral breast cancer with different pathological responses to neoadjuvant chemotherapy with different biological character

We report a case of synchronous locally advanced bilateral breast cancer with different pathological responses to neoadjuvant chemotherapy with different biological character. The patient had presented bilateral breast cancer: the left breast cancer was hormone receptor negative, human epidermal growth factor receptor-2 (HER2) positive, and classified as T4bN1M0, stage IIIb, while the right was hormone receptor positive, HER2-negative, and classified as T4bN0M0, stage IIIb. We administered four cycles of anthracycline-based therapy followed by 12 weekly cycles of taxane with trastuzumab for neoadjuvant chemotherapy. We had achieved a significant left tumor reduction after each chemotherapy, but not right tumor. Bilateral modified radical mastectomies with axillary lymph-node dissection were performed. The therapeutic effect in the left was determined as a pathological complete response, in contrast to the right side. She has no recurrence for more than five years, though she had advanced cancer with oncologic emergency. This case could be an informative experience to understand the relation of tumor biology and response to systemic therapy.

An overview of the Japan Breast Cancer Research Group (JBCRG) activities

The purpose of this article is to describe the current status and future perspectives of the Japan Breast Cancer Research Group (JBCRG). The JBCRG was organized in 2002, with the following purpose: to plan and promote clinical trials and basic research in breast cancer domestically and multilaterally; to conduct research and surveys on domestic and foreign information on medical care for breast cancer and to diffuse and highlight such information; to improve and promote clinical technologies for breast cancer; to act as an intermediary to liaise and strengthen alliances with affiliated organizations; and, to contribute to the public welfare by improving outcomes in breast cancer. The clinical trials are led by doctors/investigators in the JBCRG. And the purpose is to establish standard treatment for patients and provide substantial evidence. The JBCRG implements international collaboration in some researches/studies. As of January 2012, fourteen trials have been closed and nine are open to recruitment.

Differential pathological response to preoperative chemotherapy across breast cancer intrinsic subtypes

BACKGROUND

Breast cancer is a heterogeneous disease with a diversity of clinical behaviors. The purpose of this study was to evaluate the utility of breast cancer intrinsic subtypes in the prediction of pathological complete response (pCR) in a cohort of breast cancer patients receiving preoperative chemotherapy.

METHODS

Patients with stage II/III breast cancer received 4 cycles of XT (capecitabine and docetaxel) followed by 4 cycles of FEC (fluorouracil, epirubicin, and cyclophosphamide) as preoperative chemotherapy. Tumors were classified as luminal A, luminal B, luminal/HER2, HER2, basal-like, or non-basal-like triple negative by immunohistochemical analysis in core needle biopsy samples at baseline.

RESULTS

The overall pCR rate was 11.9% (12/101). Multivariate analysis showed that intrinsic subtype was an independent factor to predict pCR. With luminal A patients as the reference group, luminal B (OR = 16.39; 95% CI 1.44-185.88; p = 0.024), HER2 (OR = 14.73; 95% CI 1.19-180.84; p = 0.035), and basal-like (OR = 13.27; 95% CI 1.27-138.79; p = 0.031) patients had a significantly higher likelihood of pCR.

CONCLUSION

The present data indicate that intrinsic subtypes may be useful predictive biomarkers of pCR in breast cancer patients treated with preoperative chemotherapy.

Pathological responses and survival of patients with human epidermal growth factor receptor 2-positive breast cancer who received neoadjuvant chemotherapy including trastuzumab

BACKGROUND

The effectiveness of neoadjuvant chemotherapy is evaluated on the basis of pathological responses and survival outcome, because achievement of a pathological complete response (pCR) is a good predictor of long-term survival. However, few studies have assessed the survival of breast cancer patients who received neoadjuvant chemotherapy including trastuzumab.

METHODS

The records of 161 breast cancer patients who received neoadjuvant chemotherapy between January 2006 and December 2011 were retrospectively reviewed. The patients were categorized into 4 subgroups on the basis of the status of the estrogen receptor (ER), the progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). HER2-positive patients received trastuzumab-based regimens. Pathological responses and survival were analyzed on the basis of breast cancer subtypes.

RESULTS

The pCR results obtained were: luminal A and B (ER and/or PR-positive, HER2-negative), 6.3 % (5/79 cases); luminal-HER2 hybrid (ER and/or PR-positive, HER2-positive), 25.0 % (5/20 cases); HER2-enriched (ER and PR-negative, HER2-positive), 63.0 % (17/27 cases); and triple-negative (ER and PR-negative, HER2-negative), 25.7 % (9/35 cases). Achievement of pCR was a good predictor of disease-free survival in the HER2-enriched group. Overall survival of patients with pCR was slightly, but not significantly, better in the HER2-enriched and triple-negative subgroups.

CONCLUSION

Responses and survival after neoadjuvant chemotherapy including trastuzumab of patients with HER2-positive tumors differed among disease subtypes. Our findings suggest that disease subtype is an important determinant of the efficacy of neoadjuvant chemotherapy.

CD133 is a useful surrogate marker for predicting chemosensitivity to neoadjuvant chemotherapy in breast cancer

Background

Neoadjuvant chemotherapy (NAC) is a standard care regimen for patients with breast cancer. However, the pathologic complete response (pCR) rate remains at 30%. We hypothesized that a cancer stem cell marker may identify NAC-resistant patients, and evaluated CD133 and ALDH1 as a potential surrogate marker for breast cancer. The aim of this study was to find a surrogate maker to predict chemosensitivity of NAC for breast cancer.

Methodology/Findings

A total of 102 patients with breast cancer were treated with NAC consisting of epirubicin followed by paclitaxel. Core needle biopsy (CNB) specimens and resected tumors were obtained from all patients before and after NAC, respectively. Chemosensitivity and prognostic potential of CD133 or ALDH1 expression was evaluated by immunohistochemistry. Clinical CR (cCR) and pCR rates were 18% (18/102) and 29% (30/102), respectively. Forty-seven (46%) patients had CD133-positive tumors before NAC, and CD133 expression was significantly associated with a low pCR rate (p = 0.035) and clinical non-responders. Multivariate analysis revealed that CD133 expression was significantly (p = 0.03) related to pCR. Recurrence was more frequent in patients with CD133-positive tumors (21/47, 45%) than that in patients with CD133-negative tumors (7/55, 13%). The number of patients with CD133-positive tumors (62%) after NAC was higher than that (46%) before NAC. Furthermore, most patients with CD133-positive tumors before NAC maintained the same status after NAC.

Conclusion/Significance

CD133 before NAC might be a useful marker for predicting the effectiveness of NAC and recurrence of breast cancer after NAC.

Meta-analysis of the association of breast cancer subtype and pathologic complete response to neoadjuvant chemotherapy

BACKGROUND

Pathologic complete response (pCR) is a surrogate end-point for prognosis in neoadjuvant chemotherapy (NAC) for breast cancer. We aimed to report summary estimates of the proportion of subjects achieving pCR (pCR%) by tumour subtype, and to determine whether subtype was independently associated with pCR, in a study-level meta-analysis.

METHODS

We systematically identified NAC studies reporting pCR data according to tumour subtype, using predefined eligibility criteria. Descriptive, qualitative and quantitative data were extracted. Random effects logistic meta-regression examined whether pCR% was associated with subtype, defined using three categories for model 1 [hormone receptor positive (HR+/HER2-), HER2 positive (HER2+), triple negative (ER-/PR-/HER2-)] and 4 categories for model 2 [HER2+ further classified as HER2+/HR+ and HER2+/HR-]. Subtype-specific odds ratios (OR) were calculated and were adjusted for covariates associated with pCR in our data.

RESULTS

In model 1, based on 11,695 subjects from 30 eligible studies, overall pooled pCR% was 18.9% (16.6-21.5%), and in model 2 (20 studies, 8095 subjects) pooled pCR% was 18.5% (16.2-21.1%); tumour subtype was associated with pCR% (P<0.0001) in both models. Subtype-specific pCR% (model 2) was: 8.3% (6.7-10.2%) in HR+/HER2- [OR 1/referent], 18.7% (15.0-23.1%) in HER2+/HR+ [OR 2.6], 38.9% (33.2-44.9%) in HER2+/HR- [OR 7.1] and 31.1% (26.5-36.1%) in triple negative [OR 5.0]; pCR% was significantly higher for the HER2+/HR- compared with the triple negative subtype, however pCR% was very similar for these subtypes (and OR=5.0 both subtypes) when studies using HER2-directed therapy with NAC were excluded from the model. Neither sensitivity analysis (excluding unknown subtypes), nor adjustment for associated covariates, substantially altered our findings.

INTERPRETATION

This meta-analysis provides evidence of an independent association between breast cancer subtype and pCR; odds of pCR were highest for the triple negative and HER2+/HR- subtypes, with evidence of an influential effect on achieving pCR in the latter subtype through inclusion of HER2-directed therapy with NAC.

Tumor-infiltrating lymphocytes are important pathologic predictors for neoadjuvant chemotherapy in patients with breast cancer

Neoadjuvant chemotherapy or preoperative systemic therapy is increasingly considered for patients with operable breast cancer. Patients with breast cancer were examined for pathologic factors predictive of response to neoadjuvant chemotherapy, using an anthracycline-based regimen. For clinical histomorphology and biomarkers, factors were compared among 16 pathologically complete responses and 52 nonpathologically complete responses, using univariate analysis and multivariate regression analysis of principal components, using preneoadjuvant chemotherapy needle biopsy samples as follows: degree of tumor-infiltrating lymphocytes, histologic grade, biology-based tumor type (hormone receptors and HER2 [human epidermal growth factor receptor type 2]), age, clinical TNM stage, and TNM staging. In univariate analysis, high tumor-infiltrating lymphocyte, high histologic grade, and hormone receptors(-)/HER2(+) were significantly associated with pathologically complete responses (93.7%, P < .0001; 81.3%, P = .0206; 43.7%, P = .014, respectively). In multivariate principal component regression analysis, high tumor-infiltrating lymphocytes were the best independent predictor for pathologically complete responses (odds ratio, 4.7; confidence interval, 2.2-10.06; P < .0001). Among tumor-infiltrating lymphocytes and biology-based tumor types, patients with high tumor-infiltrating lymphocytes had pathologically complete responses more than nonpathologically complete responses, especially in the hormone receptors(-)/HER2(+) group. Among high tumor-infiltrating lymphocyte cases, T lymphocytes showed more predominant tendency than B lymphocytes in the pathologically complete responses cases, compared with nonpathologically complete responses cases. These findings indicate that high tumor-infiltrating lymphocytes are important predictors of pathologically complete responses to neoadjuvant chemotherapy, especially in the hormone receptors(-)/HER2(+) group.

Activation of p38 MAPK by oxidative stress underlying epirubicin-induced vascular endothelial cell injury

Epirubicin, an anthracycline antitumor drug, often causes vascular injury such as vascular pain, phlebitis, and necrotizing vasculitis. However, an effective prevention for the epirubicin-induced vascular injury has not been established. The purpose of this study is to identify the mechanisms of cell injury induced by epirubicin in porcine aorta endothelial cells (PAECs). PAECs were exposed to epirubicin for 10 min followed by further incubation without epirubicin. The exposure to epirubicin (3-30 μM) decreased the cell viability concentration and time dependently. Epirubicin increased the activity of caspase-3/7, apoptotic cells, and intracellular lipid peroxide levels, and also induced depolarization of mitochondrial membranes. These intracellular events were reversed by glutathione (GSH) and N-acetylcysteine (NAC), while epirubicin rather increased intracellular GSH slightly and L-buthionine-(S,R)-sulfoximine, a specific inhibitor of GSH synthesis, had no effect on the epirubicin-induced cell injury. The epirubicin-induced cell injury and increase of caspase-3/7 activity were also attenuated by p38 mitogen-activated protein kinase (MAPK) inhibitors, SB203580 and PD169316. Moreover, epirubicin significantly enhanced the phosphorylation of p38 MAPK, and these effects were attenuated by GSH and NAC. In contrast, a c-Jun N-terminal kinase inhibitor SP600125, an extracellular signal-regulated kinase inhibitor PD98059, and a p53 inhibitor pifithrin α did not affect the epirubicin-induced cell injury and increase of caspase-3/7 activity. These results indicate that an activation of p38 MAPK by oxidative stress is involved in the epirubicin-induced endothelial cell injury.

Ipsilateral breast tumor recurrence (IBTR) in patients with operable breast cancer who undergo breast-conserving treatment after receiving neoadjuvant chemotherapy: risk factors of IBTR and validation of the MD Anderson Prognostic Index

BACKGROUND

There is limited information about the risk factors for ipsilateral breast tumor recurrence (IBTR) after patients undergo breast-conserving surgery plus radiotherapy (breast-conserving treatment [BCT]) subsequent to neoadjuvant chemotherapy (NAC). The objective of the current study was to analyze these risk factors.

METHODS

The authors collected data from 375 patients who underwent BCT and received NAC and analyzed the risk of IBTR associated with undergoing BCT after NAC. The usefulness of the MD Anderson Prognostic Index (MDAPI) for IBTR also was validated using the current data set.

RESULTS

The median follow-up was 47.8 months, and the 4-year IBTR-free survival rate was 95.6%. Multivariate analysis demonstrated that estrogen receptor (ER) status and multifocality of the residual tumor were associated significantly with IBTR-free survival. In addition, patients who had ER-positive and human epidermal growth factor 2 (HER2)-negative tumors did not develop IBTR during the observation period. Although prognostic stratification according to MDAPI was relatively good for the prediction of IBTR in the study patients, the IBTR rate in the high-risk group was not very high and was lower than that in the intermediate-risk group. Multivariate analyses demonstrated that IBTR was an independent predictive factor for overall survival.

CONCLUSIONS

ER status and multifocality of the residual tumor after NAC were independent predictors of IBTR after BCT. The MDAPI was barely adaptable to the study patients in terms of predicting IBTR. Patients with ER-positive and HER2-negative tumors had a favorable prognosis, whereas patients who developed IBTR after NAC had significantly worse overall survival. The authors propose a new IBTR prognostic index using the 2 factors that were identified as predictive of IBTR: ER status and multifocality of the residual tumor.

Randomized phase II study of primary systemic chemotherapy and trastuzumab for operable HER2 positive breast cancer

BACKGROUND

In primary systemic therapy in patients with human epidermal growth factor receptor 2 positive (HER2(+)) breast cancer, improvements in pathologic complete response (pCR) rate have been achieved by administering trastuzumab.

PATIENTS AND METHODS

Patients with stage II or IIIA HER2(+) operable breast cancer were randomly assigned to receive four 3-weekly cycles of FEC (5-fluorouracil 500 mg/m(2), epirubicin 100 mg/m(2), cyclophosphamide 500 mg/m(2)) followed by 4 cycles of 3-weekly trastuzumab (8 mg/kg week 1 and then 6 mg/kg) with either 12 weekly doses of paclitaxel 80 mg/m(2) (FEC-PH) or 4 cycles of 3-weekly docetaxel 75 mg/m(2) (FEC-DH).

RESULTS

Between March 2007 and June 2008, 102 patients were enrolled. Forty-nine patients receiving FEC-PH and 47 receiving FEC-DH were assessable for efficacy and safety. Eighty-four patients completed treatment and underwent surgery. There was no significant difference in the pCR rate between the 2 groups (46.9% [95% CI, 33.7%-60.6%] with FEC-PH vs. 42.6% [95% CI, 29.5%-56.8%] with FEC-DH; P = .67). Analysis by hormone receptor (HR) status showed pCR rates of 54.2% (32/59) in HR(-) tumors and 29.7% (11/37) in HR(+) tumors (P = .02). Among HR(-) tumors, the pCR rates were 65.4% and 45.5% in patients treated with FEC-PH and FEC-DH, respectively (P = .13).

CONCLUSIONS

There was no significant difference in pCR rate between FEC-PH and FEC-DH. Both regimens achieved higher pCR rates in HR(-) than HR(+) breast cancer, and there was a trend toward higher pCR in HR(-) tumors with FEC-PH compared with FEC-DH. Further investigation is warranted to explore the relationship between efficacy and HR status.

Racial differences in acute toxicities of neoadjuvant or adjuvant chemotherapy in patients with early-stage breast cancer

BACKGROUND

Racial disparities in breast cancer outcomes are attributed to differences in baseline tumour characteristics and biology, stage, age, ethnic background and socioeconomic factors. However, little is known about racial differences in treatment-related toxicities. We hypothesised that racial/ethnic differences result in differential tolerance to chemotherapy potentially, leading to compromised dose intensity/density of chemotherapy in patients with early-stage breast cancer.

METHODS

Data were collected from patients treated at five international centers for early breast cancer with the same adjuvant/neoadjuvant chemotherapy (FEC 100: fluorouracil 500mg/m(2), epirubicin 100mg/m(2), and cyclophosphamide 500mg/m(2),every 21d for 3-6 cycles). Toxicities were assessed by first episode of ⩾grade 2 toxicity.

RESULTS

Toxicities were compared according to four race/ethnicity groups (103 Caucasian, 30 African American, 164 Asian, and 34 Hispanic patients). Tumour characteristics across four race/ethnicity groups were similar. Asians had a significantly higher rate of grade 3 haematologic toxicity than Caucasians, African Americans or Hispanic women (32%, 16%, 10%, and 15%, respectively; p<0.05). In multivariate analysis, only lower BMI was associated with a higher incidence of ⩾grade 3 toxicities. However, no significant differences in chemotherapy dose intensity/density were shown across the four race/ethnicity groups.

CONCLUSION

Racial differences in acute toxicity were noted in women with breast cancer who were treated with FEC 100 chemotherapy, suggesting that extrapolating toxicities from chemotherapy across ethnicities is not possible and emphasising the need to validate safety of chemotherapeutic regimens in patients of different ethnicities by enhancing the participation of minorities in clinical trials.

Meta-analysis confirms achieving pathological complete response after neoadjuvant chemotherapy predicts favourable prognosis for breast cancer patients

Neoadjuvant chemotherapy (NAC) has become a widely accepted method of sequencing systemic therapy for breast cancer treatment. While 'response to chemotherapy' in the neoadjuvant setting has been utilised to predict prognosis, the published data are inconsistent. The present meta-analysis was conducted to determine whether the pathologic response to NAC predicts for outcomes. Papers were selected from the PubMed database based on defined inclusion and exclusion criteria. Parameters such as number/percentage of patients having pCR and outcome statistics (i.e. overall survival (OS), disease-free survival (DFS), relapse-free survival (RFS)) were collected. The analysis included 16 studies with 3776 patients. The summary odds ratio (OR) estimating the association of OS with pCR was 3.44 (95% confidence interval [95%CI]: 2.45-4.84), with similar findings for DFS (OR=3.41, 95%CI: 2.54-4.58) and RFS (OR=2.45, 95%CI: 1.59-3.80). No obvious statistical heterogeneity was detected. Funnel plots and Egger's tests did not reveal publication bias. This meta-analysis confirms that pathologic response is a prognostic indicator for RFS, DFS and OS and suggests that patients achieving pCR after NAC have favourable outcomes.

Tumor-infiltrating lymphocytes are correlated with response to neoadjuvant chemotherapy in triple-negative breast cancer

The purpose of the present study was to identify histological surrogate predictive markers of pathological complete response (pCR) to neoadjuvant chemotherapy (NAC) in triple-negative breast cancer (TNBC). Among 474 patients who received NAC and subsequent surgical therapy for stage II-III invasive breast carcinoma between 1999 and 2007, 102 (22%) had TNBC, and 92 core needle biopsy (CNB) specimens obtained before NAC were available. As controls, CNB specimens from 42 tumors of the hormone receptor-negative and HER2-positive (HR-/HER2+) subtype and 46 tumors of the hormone receptor-positive and HER2-negative (HR+/HER2-) subtype were also included. Histopathological examination including tumor-infiltrating lymphocytes (TIL) and tumor cell apoptosis, and immunohistochemical studies for basal markers were performed, and the correlation of these data with pathological therapeutic effect was analyzed. The rates of pCR at the primary site were higher for TNBC (32%) and the HR-/HER2+ subtype (21%) than for the HR+/HER2- subtype (7%) (P = 0.006). Expression of basal markers and p53, histological grade 3, high TIL scores, and apoptosis were more frequent in TNBC and the HR-/HER2+ subtype than in the HR+/HER2- subtype (P = 0.002 for TIL and P < 0.001 for others). In TNBC, the pCR rates of tumors showing a high TIL score and of those showing a high apoptosis score were 37 and 47%, respectively, and significantly higher or tended to be higher than those of the tumors showing a low TIL score and of the tumors showing a low apoptosis score (16 and 27%, respectively, P = 0.05 and 0.10). In a total of 180 breast cancers, the pCR rates of the tumors showing a high TIL score (34%) and of those showing a high apoptosis score (35%) were significantly higher than those of the tumors showing a low TIL score (10%) and those of the tumors showing a low apoptosis score (19%) (P = 0.0001 and 0.04, respectively). Histological grade and basal marker expression were not correlated with pCR. Although the whole analysis was exploratory, the degree of TIL correlated with immune response appear to play a substantial role in the response to NAC in TNBC.

Future treatment strategies for metastatic breast cancer: curable or incurable?

Current Japanese and American guidelines for the surveillance of patients diagnosed with early stage breast cancer recommend regular follow-up including mammography, history, and physical examination; however, additional routine laboratory and imaging studies are not recommended because there is no evidence of improved clinical outcomes associated with the early detection of distant metastasis. Metastatic breast cancer (MBC) remains a largely incurable disease. The goals of treatment for MBC are to maintain quality of life and prolong survival. However, despite the emergence of new concepts including oligometastases, cancer stem cells, and the development of individualized therapies, clinical management and treatment guidelines remain largely unchanged. The future prospects for personalized management strategies for patients with MBC are described in this review.

Current strategy for triple-negative breast cancer: appropriate combination of surgery, radiation, and chemotherapy

Triple-negative breast cancer (TNBC) often grows rapidly and has poor outcomes, with a high recurrence rate and a short interval between recurrence and death. New molecular-targeted therapies are being developed, but cannot be used at present. Other strategies for the management of TNBC are needed. TNBC is characterized by an expanding growth pattern without extensive intraductal spread and is a good candidate for breast-conserving therapy (BCT) with sufficient margins. The local recurrence rate after BCT is not high as those of other subtypes of breast cancer. In contrast, the regional recurrence rate is higher in TNBC than in other subtypes. Sentinel node biopsy and axillary resection should therefore be performed with the upmost caution. Radiation therapy has been shown to be useful for the management of TNBC. Radiation therapy of the chest wall after mastectomy and the regional area as well as the breast after breast-conserving surgery should be considered. Chemotherapy is the only systemic treatment available for TNBC. In our hospital, a combination of cyclophosphamide, epirubicin, and 5-fluorouracil (FEC) followed by docetaxel (DTX) or DTX followed by FEC has been used to treat tumors more than 2 cm in diameter or node-positive breast cancer. Neoadjuvant chemotherapy with these regimens has produced pathological complete response (pCR) rates higher than 20% in patients with TNBC, regardless of the specific order of agents. Tumors tend to shrink towards their center and can be a good indication for BCT. After 3 years, a pCR is associated with good outcomes, whereas a non-pCR sometimes results in distant recurrence, even when residual tumor is minimal. Patients should be closely observed during neoadjuvant chemotherapy. If there is any evidence of tumor progression, the chemotherapeutic regimen should be modified or surgery performed, without losing the opportunity to administer potentially effective treatment. Several studies indicate that neoadjuvant chemotherapy with platinum-based regimens is effective for TNBC and is thus an important treatment option. We have used regimens combining epirubicin and cyclophosphamide (EC) to treat tumors 1-2 cm in diameter without node metastasis, and 2 of 21 patients presented with distant metastases (disease-free interval, 2 and 5 years). We have not used systemic therapy to treat tumors 1 cm or less in diameter without node metastasis, and all 8 patients are alive without recurrence for more than 4 years. After distant recurrence in patients with TNBC, the same chemotherapeutic agents as those used for other subtypes of breast cancer are recommended, but the response is often disappointing, leading to poor outcomes. TNBC presents with different clinical features from other subtypes. The treatment strategy should be selected according to the characteristics of the specific subtype of breast cancer.

Shift in cytotoxic target from estrogen receptor-positive to estrogen receptor-negative breast cancer cells by trastuzumab in combination with taxane-based chemotherapy

Trastuzumab has shown significant clinical benefits in patients with operable and metastatic HER2-positive breast cancer. However, the biological mechanism of the additional effect of trastuzumab administered in combination with conventional chemotherapy is poorly understood. We performed a retrospective analysis of 55 patients with HER2-positive breast cancer treated with anthracycline and taxane (chemotherapy alone; CT), or trastuzumab in combination with taxane-based chemotherapy (CT+T) for neoadjuvant chemotherapy. We determined the therapeutic efficacies [clinical (CR) and pathological complete responses (pCR)] and changes in the proportion of positive cells for each biomarker pre- to post-neoadjuvant chemotherapy for each treatment regimen. Clinical-CR and quasi-pCR rates defined as the absence of invasive tumors or only a few remaining invasive tumor cells were 6.9 and 31.0% in the CT group and 46.2 and 65.4% in the CT+T group, respectively. In the CT group, the proportion of estrogen receptor (ER)-/progesterone receptor (PgR)-positive cells decreased significantly following treatment (ER, 73.5 vs. 50.9%; P=0.02). Changes in the proportion of ER-/PgR-positive cells were not noted in the CT+T group (ER, 81.9 vs. 80.3%; P=0.61), although a relatively greater decrease in the proportion of Ki-67-positive cells was found in the CT+T group than that in the CT group (-26.5 vs. -13.7%). These findings indicate that CT+T inhibits ER-negative and Ki-67-positive breast cancer cells. In conclusion, trastuzumab sensitized ER-negative proliferative cells to cytotoxic chemotherapy. This finding may indicate an additional clinical effect of trastuzumab when administered in combination with conventional chemotherapy as neoadjuvant chemotherapy for HER2-positive breast cancer.

Neoadjuvant endocrine therapy for postmenopausal patients with hormone receptor-positive early breast cancer: a new concept

Patients with resectable, nonmetastatic (stage I-IIIA) breast cancer usually receive adjuvant (postoperative) systemic therapy to control micrometastasis and prevent recurrence. Neoadjuvant (preoperative) chemotherapy is a standard treatment for resectable breast cancer, potentially enabling patients to undergo partial dissection. However, it has been reported that neoadjuvant chemotherapy has a limited effect in patients with hormone receptor-positive disease in terms of pathologic complete response rate, and in elderly patients there may be safety concerns. Furthermore, the appropriateness of chemotherapy for luminal early breast cancer [defined as hormone receptor-positive and human epidermal growth factor receptor-2 (HER2)-negative tumors] is an important clinical issue. We determine the need for chemotherapy in postmenopausal patients with hormone receptor-positive, HER2-negative, lymph node-negative early breast cancer according to clinicopathologic factors, including multigene signature. The National Surgical Adjuvant Study of Breast Cancer (N-SAS-BC06) New primary Endocrine-therapy Origination Study (NEOS) is a randomized phase III trial conducted in Japanese centers. It is evaluating adjuvant endocrine therapy, with or without chemotherapy, in patients with postmenopausal breast cancer that has responded to neoadjuvant letrozole. The aims of this trial are to: define patients who might not require chemotherapy by using their response to neoadjuvant endocrine therapy; analyze the relationship between neoadjuvant endocrine therapy and long-term prognosis; and analyze the correlation between clinical and pathologic response to neoadjuvant hormonal therapy with additional postoperative chemotherapy. We hope that the results of this trial will lead to the development of a new clinical strategy of pre- and postsurgical treatment for luminal breast cancer.

Chemotherapy with PLGA microspheres containing docetaxel decreases angiogenesis in human hepatoma xenograft

To investigate the antiangiogenic effect of sustained-release poly (lactic-co-glycolic acid) microspheres containing docetaxel (PMCD) in human hepatoma xenograft. PMCD were prepared by solvent evaporation method with an encapsulation efficiency of 98.7% and a release period of about 3 weeks in vitro. PMCD were intratumorally injected once for mice bearing a human hepatocellular carcinoma. On day 21 post-treatment, the inhibition rate of tumor growth was 72.7% in the high-dose group, indicating a significant antitumor activity. Meanwhile, excellent antiangiogenic effect was observed based on the contrast-enhanced ultrasonography as well as microvessel density determination. Additionally, the real-time fluorescence quantitative PCR revealed that the expressions of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and angiopoietin-2 (Ang2) genes were down-regulated significantly. Interstitial chemotherapy using PMCD was highly effective and safe for the treatment of the human hepatoma xenograft and that decreasing angiogenesis could be one of the most important mechanisms involved in the antitumor activity.

A histopathological study for evaluation of therapeutic effects of radiofrequency ablation in patients with breast cancer

PURPOSE

To reveal the rate of complete therapeutic effect of radiofrequency ablation (RFA) and its correlation with tumor size by the histopathological examination of surgically resected early breast cancers.

METHODS

For 28 patients who received RFA and subsequent surgical therapies for early breast cancer treatment, the effect of RFA was evaluated by both histopathological examination and nicotinamide adenine dinucleotide (NADH)-diaphorase staining of resected tumor specimens according to the criteria described by Seki et al. (this issue). The correlation of 100% RFA effect with tumor parameters including tumor size and the presence of extensive intraductal component (EIC) was examined.

RESULTS

The mean size and invasive size of the primary tumors were 2.21 cm (ranging from 0.6 to 5.0 cm) and 1.44 cm (ranging from 0 to 5.0 cm), respectively. By examining hematoxylin-eosin (HE) sections, the effectiveness of RFA was found to be 100% in 16 tumors (57%). However, the effectiveness of RFA was found to be 100% in 22 cases (79%) examined by NADH-diaphorase staining of frozen sections containing part of tumorous and nontumorous tissues. The accuracy of diagnosis of complete RFA effect using NADH-diaphorase staining with reference to HE was 79% (22 of 28) with 100% (16 of 16) sensitivity and 50% (6 of 12) specificity. The rate of 100% RFA effect by HE examination was higher in EIC(-) tumors (13 of 17, 76%) than in EIC(+) tumors (1 of 9, 11%) (P = 0.0022), and was higher in tumors of ≤ 1.5 cm (10 of 11, 91%) than in tumors of >1.5 cm (6 of 17, 35%; P = 0.0034). All five tumors of ≤ 1.0 cm showed 100% RFA effect, but 3 (27%) of 11 tumors of >1.0 and ≤ 2.0 cm and 9 (75%) of 12 tumors of > 2.0 cm showed suboptimal RFA effect by HE.

CONCLUSIONS

Tumor size of ≤ 1.5 cm, strictly ≤ 1.0 cm, could be an indication for RFA if a complete histological therapeutic effect is mandatory.

Clinicopathological features and treatment strategy for triple-negative breast cancer

Breast cancers are divided into at least 4 subtypes on the basis of gene expression profiles and expression of receptors (hormone receptors (HR) and HER2) as measured by immunohistochemistry. These subtypes have different prognoses and responses to treatments such as endocrine manipulation, anti-HER2 therapy, and chemotherapy. Triple-negative breast cancer (TNBC) is immunohistochemically defined as lacking estrogen and progesterone receptors and not overexpressing HER2. TNBC accounts for approximately 15% of breast cancer patients, and is more chemosensitive but has a worse prognosis than the HR-positive/HER2-negative phenotype. TNBC is a heterogeneous disease that does not offer specific targets in the same way as HR-positive and HER2-positive breast cancers, and is similar to basal-like breast cancer and BRCA1-related breast cancer. At present, the lack of highly effective therapeutic targets for TNBC leaves standard chemotherapy, for example the combination of anthracycline and taxane, as the only medical treatment, but this is insufficiently efficacious. Novel approaches for TNBC, for example DNA damaging agents, PARP-1 inhibitors, receptor tyrosin kinase inhibitors (TKIs), and antiangiogenesis agents, have been examined in clinical settings. Concerning therapeutic strategies for TNBC, it is most important to develop novel effective approaches for TNBC treatment and high-throughput predictive tools for standard chemotherapy and novel agents.

Therapeutic usefulness of postoperative adjuvant chemotherapy with Tegafur-Uracil (UFT) in patients with breast cancer: focus on the results of clinical studies in Japan

In Japan, the history of postoperative chemotherapy for breast cancer started with 5-fluorouracil (5-FU), launched in the 1980s. Currently, oral fluoropyrimidine-based regimens indicated for the treatment of breast cancer in Japan include tegafur plus uracil (UFT); tegafur, gimeracil, and oteracil (TS-1); doxifluridine; and capecitabine. In particular, UFT represents an important option for long-term treatment because of minimal adverse events and the potential for long-term maintenance of effective plasma concentrations of 5-FU to inhibit micrometastasis after surgery. Therefore, various clinical studies of postoperative adjuvant chemotherapy with UFT have been conducted in patients with completely resected tumors. Recent studies have shown that UFT prolongs survival after tumor resection in patients with gastric cancer, colorectal cancer, and lung cancer. In patients with breast cancer, large clinical trials of UFT-based postoperative chemotherapy conducted in Japan have shown that UFT is useful for the treatment of intermediate-risk patients with no lymph node metastasis. This paper reviews the results of clinical studies of UFT conducted in Japan to assess the therapeutic usefulness of this oral 5-FU. The types of patients most likely to benefit from UFT are discussed on the basis of currently available evidence and a global consensus of treatment recommendations. The optimal timing of endocrine therapy and strategies for postoperative adjuvant chemotherapy with UFT in patients with breast cancer are also discussed.

Neo(adjuvant) trastuzumab treatment: current perspectives

International collaboration with adjuvant trastuzumab trials showed that trastuzumab treatment improves disease-free and overall survival after or in combination with adjuvant chemotherapy. Trastuzumab treatment is already regarded as the standard therapy for HER2-positive breast cancer patients by many guidelines around the world. However, there are many uncertain issues concerning trastuzumab adjuvant treatment, for example duration of therapy, eligibility of elderly women, usability for small tumors (1 cm or less in size), and molecular marker status for individualized treatment in HER2-positive breast cancer.

Gene and chromosomal alterations in sporadic breast cancer: correlation with histopathological features and implications for genesis and progression

A number of gene and chromosome alterations have been identified in sporadic breast carcinomas, and their clinical implications have been investigated. Changes in proto-oncogenes and tumor-suppressor genes, e.g., HER2, p53, and E-cadherin, and various numerical and structural chromosome alterations are strongly correlated with histological type and grade in breast carcinomas. The amount of information on these alterations has been dramatically increased by the introduction of high-throughput molecular cytogenetic approaches. In the near future, breast cancers will be classified into specific groups according to their profile of gene and chromosome alterations, allowing more effective personalized therapies targeting the associated molecular pathways.

Individualization of breast cancer based on histopathological features and molecular alterations

Histopathological findings and molecular alterations well reflect the biological properties of individual primary breast carcinomas. Specifically, pT (size of the invasive component), pN (number of metastatic lymph nodes), histological or nuclear grade, lymphovascular invasion, hormone receptors, and HER2 (c-erbB-2) gene overexpresson or amplification are known to be effective markers for assessing the risk of operable primary breast carcinoma, albeit incompletely. It is expected that additional molecular markers and novel diagnostic tools will be developed in the future to facilitate a more accurate characterization of higher risk node-negative breast carcinomas.

Fluorouracil, Epirubicin, and Cyclophosphamide (FEC100) for Breast Cancer

The complexity of cancer chemotherapy requires that pharmacists be familiar with the complicated regimens and highly toxic agents used. This column reviews various issues related to preparation, dispensing, and administration of antineoplastic therapy and the agents, both commercially available and investigational, used to treat malignant diseases.

Nek2 as a novel molecular target for the treatment of breast carcinoma

We investigated the role of Nek2, a member of the serine-threonine kinase family, in the tumorigenic growth of breast carcinoma. Increased expression of Nek2 was observed in all breast carcinoma cell lines examined (BT20, BT474, Hs578T, MCF7, MDA-MB-231, T47D, and ZR-75-1) by immunoblotting. By treatment with Nek2 short interfering RNA (siRNA), expression of Nek2 was clearly decreased in both estrogen receptor (ER)-positive (MCF7) and ER-negative (MDA-MB-231) breast carcinoma cell lines. Cell growth, colony formation in soft agar, and in vitro invasiveness of these cell lines were substantially suppressed by Nek2 siRNA treatment. In a xenograft nude mouse model with subcutaneous implantation of MCF7 or MDA-MB-231, subcutaneous injection of Nek2 siRNA around the tumor nodules resulted in a reduction of tumor size compared with those of control siRNA injection. Taken together, Nek2 appears to play a pivotal role in tumorigenic growth of breast carcinoma cells, and could be a useful therapeutic molecular target for the treatment of breast carcinoma both in ER-positive and ER-negative cases.