Incidence and prognostic significance of complete axillary downstaging after primary chemotherapy in breast cancer patients with T1 to T3 tumors and cytologically proven axillary metastatic lymph nodes

Clinical implications of chemotherapy-induced tumor gene expression in human breast cancers

IMPORTANCE OF THE FIELD

There has been much interest in generating gene signatures to predict treatment response in breast cancer.

AREAS COVERED IN THIS REVIEW

There are at least 15 published studies that describe baseline tumor gene signatures predicting chemotherapy sensitivity. As an extension of these baseline studies, there have been at least 8 published studies evaluating chemotherapy-induced tumor genomic changes over time in human breast cancers.

WHAT THE READER WILL GAIN

Studies on chemotherapy-induced gene expression changes were reviewed in detail. Drug-induced biological changes within the tumor shed light on mechanisms of drug resistance and provided valuable insights regarding genes and pathways that were regulated by different drugs, including therapeutic targets that could be exploited to overcome resistance. One study also suggested post-chemotherapy gene signatures to be more predictive of response and survival than the unchallenged baseline signatures.

TAKE HOME MESSAGE

Studies on chemotherapy-induced changes, although informative, are logistically demanding to execute, often with significant attrition of collected samples resulting in small datasets. They are further limited by heterogeneity of study population, chemotherapy regimens used, timing of the post-therapy sample and definition of response endpoint, making cross-comparisons of studies and data interpretation difficult. Future studies should address these limitations, and should involve larger sample sets and prospective studies for validation.

Sentinel lymph node biopsy before or after neoadjuvant chemotherapy: pros and cons

This article summarizes the relative pros and cons surrounding the timing of sentinel lymph node (SLN) biopsy in patients undergoing neoadjuvant chemotherapy. Several institutions initiated prospective trials of SLN biopsy performed after neoadjuvant chemotherapy in conjunction with a completion axillary lymph node dissection, with the goal of ultimately showing that SLN biopsy could be safely and accurately performed after the patient completed systemic therapy. Other institutions adopted a policy of performing SLN biopsy before initiation of chemotherapy. This avoided the issue surrounding the accuracy of SLN biopsy after chemotherapy and potentially provided information that might influence adjuvant therapy decisions. This article addresses the clinical questions regarding the 2 approaches including the accuracy of the procedure and the prognostic information gleaned.

Axillary sentinel node biopsy after neoadjuvant chemotherapy

INTRODUCTION

The role of sentinel lymph node biopsy (SLNB) in patients with locally advanced breast cancer (LABC) with potentially sterilized axillary lymph nodes after neoadjuvant chemotherapy (NAC) remains unclear.

PATIENTS AND METHODS

Between 2002 and 2008, SLNB with both blue-dye and radioisotope injection was performed in 77 patients with LABC whose cytopathologically confirmed positive axillary node(s) became clinically negative after NAC. Factors associated with SLN identification and false-negative rates, presence of non-sentinel lymph node (non-SLN) metastasis were analyzed retrospectively.

RESULTS

SLNB was successful in 92% of the patients. Axillary status was predicted with 90% accuracy and a false-negative rate of 13.7%. Patients with residual tumor size >2 cm had a decreased SLN identification rate (p=0.002). Axillary nodal status before NAC (N2 versus N1) was associated with higher false-negative rates (p=0.04). Positive non-SLN(s) were more frequent in patients with multifocal/multicentric tumors (versus unifocal; p=0.003) and positive lymphovascular invasion (versus negative; p=0.0001). SLN(s) positive patients with pathologic tumor size >2 cm (versus <or=2 cm; p=0.004), positive extra-sentinel lymph node extension (versus negative; p=0.002) were more likely to have metastatic non-SLN(s).

CONCLUSIONS

SLNB has a high identification rate and modest false-negative rate in LABC patients who became clinically axillary node negative after NAC. Residual tumor size and nodal status before NAC affect SLNB accuracy. Additional involvement of non-SLN(s) increases with the presence of multifocal/multicentric tumors, lymphovascular invasion, residual tumor size >2 cm, and extra-sentinel node extension.

Lymphangiogenesis and lymphatic metastasis in breast cancer

Lymphatic metastasis is the main prognostic factor for survival of patients with breast cancer and other epithelial malignancies. Mounting clinical and experimental data suggest that migration of tumor cells into the lymph nodes is greatly facilitated by lymphangiogenesis, a process that generates new lymphatic vessels from pre-existing lymphatics with the aid of circulating lymphatic endothelial progenitor cells. The key protein that induces lymphangiogenesis is vascular endothelial growth factor receptor-3 (VEGFR-3), which is activated by vascular endothelial growth factor-C and -D (VEGF-C and VEGF-D). These lymphangiogenic factors are commonly expressed in malignant, tumor-infiltrating and stromal cells, creating a favorable environment for generation of new lymphatic vessels. Clinical evidence demonstrates that increased lymphatic vessel density in and around tumors is associated with lymphatic metastasis and reduced patient survival. Recent evidence shows that breast cancers induce remodeling of the local lymphatic vessels and the regional lymphatic network in the sentinel and distal lymph nodes. These changes include an increase in number and diameter of tumor-draining lymphatic vessels. Consequently, lymph flow away from the tumor is increased, which significantly increases tumor cell metastasis to draining lymph nodes and may contribute to systemic spread. Collectively, recent advances in the biology of tumor-induced lymphangiogenesis suggest that chemical inhibitors of this process may be an attractive target for inhibiting tumor metastasis and cancer-related death. Nevertheless, this is a relatively new field of study and much remains to be established before the concept of tumor-induced lymphangiogenesis is accepted as a viable anti-metastatic target. This review summarizes the current concepts related to breast cancer lymphangiogenesis and lymphatic metastasis while highlighting controversies and unanswered questions.

Breast conservation therapy for patients with locally advanced breast cancer

Neoadjuvant chemotherapy achieves high response rates in patients with breast cancer and has been used to reduce tumor size and allow for breast conservation in individuals who initially required mastectomy. The goals of this approach are to achieve optimal locoregional control together with acceptable cosmesis. In the setting of locally advanced disease, breast preservation appears to be feasible for appropriately selected patients whose tumors show adequate downstaging in response to induction chemotherapy. Nevertheless, further prospective randomized trials are warranted to better evaluate the results of this approach as compared with mastectomy.

Accuracy of sentinel node biopsy after neoadjuvant chemotherapy in breast cancer patients: a systematic review

BACKGROUND

As neoadjuvant chemotherapy (NAC) is increasingly used to downstage patients with breast cancer, the timing of the sentinel node (SN) biopsy has become an important issue. This review was conducted to determine the accuracy of SN biopsy following NAC.

METHODS

We searched Medline, Embase and Cochrane databases from 1993 to February 2009 for studies on patients with invasive breast cancer who underwent SN biopsy after NAC followed by an axillary lymph node dissection (ALND).

RESULTS

Of 574 eligible studies, 27 were included in this review with a total study population of 2148 patients. The pooled SN identification rate was 90.9% (95% confidence interval (CI)=88.0-93.1%) and the false-negative rate was 10.5% (95% CI=8.1-13.6%). Negative predictive value and accuracy after NAC were 89.0% (95% CI=85.1-92.1%) and 94.4% (95% CI=92.6-95.8%), respectively. The reported SN success rates were heterogeneous and several variables were reported to be associated with decreased SN accuracy, i.e. initially positive clinical nodal status.

CONCLUSIONS

There is a potential role for SN biopsy following NAC which could be considered on an individual basis. However, there is insufficient evidence to recommend this as a standard procedure. Further research with subgroup analysis using variables reported to be associated with decreased SN accuracy is required in order to clearly define its value in the subgroups of breast cancer patients.

High efficacy of pre-operative trastuzumab combined with paclitaxel following doxorubicin & cyclophosphamide in operable breast cancer

BACKGROUND

Trastuzumab in combination with adjuvant chemotherapy improves disease free survival and overall survival in HER2 over-expressing breast cancer patients. Data concerning the use of trastuzumab in the neo-adjuvant setting is limited. We aimed to compare outcome of HER2 over-expressing breast cancer patients treated with either standard chemotherapy, consisting of doxorubicin, cyclophosphamide and a taxane to outcome of patients treated with the same chemotherapy regimen with the addition of trastuzumab in concurrence with paclitaxel.

METHODS

We conducted a retrospective review of all consecutive HER2 over-expressing breast cancer patients treated at the participating institutions during the study period and received neo-adjuvant therapy. Allocation to trastuzumab was not based on clinical parameters and was approved only by part of the insurers. Clinical and pathological characteristics, as well as response rate and type of surgery were analyzed.

RESULTS

Thirty seven patients received chemotherapy alone and 24 patients received chemotherapy and trastuzumab. A similar distribution of age, clinical stage and histology was noted in both groups. The rate of pathological complete response (pCR) was significantly higher among the trastuzumab-treated group compared to chemotherapy-alone group (75 vs. 24% respectively, p=0.0002). pCR in the breast was noted in 18 of 24 (75%) compared to 10 of 36 (28%, p=0.0005) and pCR in the axillary lymph nodes was noted in 19 of 20 (95%) compared to 8 of 28 (29%, p=0.0001), in the trastuzumab group compared to the chemotherapy-alone group respectively. The safety profile was similar between both groups and no clinical cardiotoxicity were noted.

CONCLUSIONS

The addition of trastuzumab to standard chemotherapy in the neo-adjuvant setting improves pathological complete response rates in HER2 over-expressing breast cancer patients.

Gene-expression microarrays provide new prognostic and predictive tests for breast cancer

Wide availability of systemic therapy agents has led to a considerable decline in mortality from breast cancer. However, the biology of breast cancer remains poorly understood. Currently, highly accurate markers to predict prognosis and probability of response to a given systemic therapy on an individual basis are lacking, and routinely used clinicopathologic variables fail to fully capture the heterogeneity of breast cancer. As a result, many patients are overtreated, whereas others may not receive the necessary therapy. It has been hypothesized that molecular differences in breast cancers might account for the heterogeneous potential in growth, invasion and metastasis in each individual tumor. Gene-expression microarrays have been extensively applied in breast cancer research in the hope that a combination of multiple genes (i.e., gene signatures) will more informatively predict disease outcome and response to a specific systemic therapy. This technique holds substantial promise for optimizing clinical decision making and tailoring therapeutic regimens to individual patients in the near future. This review focuses on the recent progression in feasibility and reliability of gene-expression microarrays in identifying new prognostic and predictive indicators of breast cancer.

Neoadjuvant chemotherapy in invasive breast cancer results in a lower axillary lymph node count

BACKGROUND

It is essential to have the highest level of confidence in axillary staging assessment. Many surgeons and pathologists believe that fewer lymph nodes are present in axillary dissection specimens of women treated by neoadjuvant chemotherapy. Consequently, the purpose of this study was to compare the lymph node counts of axillary dissection specimens from patients having received neoadjuvant chemotherapy with those of patients treated with primary operation.

STUDY DESIGN

A retrospective analysis of a prospective database from our institution identified 283 women with invasive breast cancer who underwent level I and II axillary lymph node dissections. Women from the neoadjuvant chemotherapy group (n=107) were compared with those from the primary surgery group (n=176). The total number of lymph nodes harvested was considered as a continuous variable, but also dichotomized into two categories (< 10 and >or=10). Its correlation with the different variables was analyzed.

RESULTS

The median number of lymph nodes retrieved in the neoadjuvant chemotherapy group was 10.0 (range 0 to 38) compared with 12.5 (range 0 to 30) in the control group (p=0.002). There were also significantly more patients with fewer than 10 lymph nodes recovered in the neoadjuvant group (45 versus 28%, p=0.007). Logistic regression showed that neoadjuvant chemotherapy was the only factor associated with retrieval of fewer than 10 lymph nodes.

CONCLUSIONS

This study suggests that administration of neoadjuvant chemotherapy to breast cancer patients results in a reduced number of lymph nodes retrieved in the axillary dissection specimens.

Integrating trastuzumab in the neoadjuvant treatment of primary breast cancer: Accumulating evidence of efficacy, synergy and safety

Neoadjuvant chemotherapy is used in non-metastatic breast cancer in order to eradicate micrometastatic deposits early during disease course, as well as in order to decrease tumour bulk and render surgery feasible or breast-conserving. Moreover, it offers promise to serve as an in vivo chemosensitivity assay and as a powerful predictive factor for outcome. Trastuzumab, a monoclonal antibody targeting an epitope in the extracellular domain of the Human Epidermal Growth Factor Receptor-2 (HER2/erbB-2), was found to be active in HER2-overexpressing metastatic as well as in resected breast cancer when given post-operatively. In this review, we summarise the evidence on the activity and safety of trastuzumab-containing neoadjuvant chemotherapy for the management of women with localised, irresectable or resectable breast cancer. Twenty-three published studies enrolling a total of 585 patients reported pathologic complete responses (pCR) ranging from 7 to 78% with a favourable adverse event profile, data that are presented and discussed in this review. The impact of trastuzumab on long-term outcome, the identification of surrogate biomarkers for sensitivity or resistance to antineoplastic therapy, the optimal schedule of trastuzumab administration and the more active chemotherapeutic regimen for synergism are only a few of the key points needing elucidation so as to rationalise trastuzumab-based approaches.

Primary systemic therapy for operable breast cancer: A review of clinical trials and perspectives

Primary systemic therapy represents the standard of care for locally advanced breast cancer and has becoming an attractive alternative in earlier stages. A part from the proven advantage of increasing the rate of breast conservative surgery, the up front use of systemic therapy can allow for an in vivo test of treatment sensitivity, and response to primary treatment discriminates patients at different prognosis. This review will summarize the more relevant data on the preoperative treatment with chemotherapy, hormonal therapy and targeted agents.

Axillary Management After Sentinel Lymph Node Biopsy in Breast Cancer Patients

According to the available data, sentinel lymph node (SLN) biopsy is proving to be an accurate staging technique with less post-surgical morbidity than standard axillary lymph node dissection (ALND). Survival benefits associated with SLN biopsy and, as well as the significance of IHC detected micrometastases have yet to be determined. The long term results of several multicenter trials are pending, yet preliminary results are in favor of abandoning ALND in favor of the less invasive alternative. Despite this, ALND remains the standard of care in breast cancer patients with clinically palpable axillary lymph nodes that are suspicious for metastatic disease. Although controversial, many clinicians believe that axillary metastases will precede systemic spread of disease. Therefore, axillary clearance of clinically palpable nodes could potentially quell the progression of metastases. Regardless of whether or not this theory is true, not many would argue against debulking suspicious nodal disease.

A proof-of-principle study of epigenetic therapy added to neoadjuvant doxorubicin cyclophosphamide for locally advanced breast cancer

BACKGROUND

Aberrant DNA methylation and histone deacetylation participate in cancer development and progression; hence, their reversal by inhibitors of DNA methylation and histone deacetylases (HDACs) is at present undergoing clinical testing in cancer therapy. As epigenetic alterations are common to breast cancer, in this proof-of-concept study demethylating hydralazine, plus the HDAC inhibitor magnesium valproate, were added to neoadjuvant doxorubicin and cyclophosphamide in locally advanced breast cancer to assess their safety and biological efficacy.

METHODOLOGY

This was a single-arm interventional trial on breast cancer patients (ClinicalTrials.gov Identifier: NCT00395655). After signing informed consent, patients were typed for acetylator phenotype and then treated with hydralazine at 182 mg for rapid-, or 83 mg for slow-acetylators, and magnesium valproate at 30 mg/kg, starting from day -7 until chemotherapy ended, the latter consisting of four cycles of doxorubicin 60 mg/m2 and cyclophosphamide 600 mg/m2 every 21 days. Core-needle biopsies were taken from primary breast tumors at diagnosis and at day 8 of treatment with hydralazine and valproate.

MAIN FINDINGS

16 patients were included and received treatment as planned. All were evaluated for clinical response and toxicity and 15 for pathological response. Treatment was well-tolerated. The most common toxicity was drowsiness grades 1-2. Five (31%) patients had clinical CR and eight (50%) PR for an ORR of 81%. No patient progressed. One of 15 operated patients (6.6%) had pathological CR and 70% had residual disease <3 cm. There was a statistically significant decrease in global 5mC content and HDAC activity. Hydralazine and magnesium valproate up- and down-regulated at least 3-fold, 1,091 and 89 genes, respectively.

CONCLUSIONS

Hydralazine and magnesium valproate produce DNA demethylation, HDAC inhibition, and gene reactivation in primary tumors. Doxorubicin and cyclophosphamide treatment is safe, well-tolerated, and appears to increase the efficacy of chemotherapy. A randomized phase III study is ongoing to support the efficacy of so-called epigenetic or transcriptional cancer therapy.

Maladie micrométastatique et maladie résiduelle axillaire. Exemple du cancer du sein

The knowledge of the axillary involvement is a major prognosis factor for breast cancer and an important parameter for treatment decision. Nevertheless, two recent current medical situations have occurred in breast cancer, changing our management. First, with the development of mass screening and sentinel lymph nodes biopsies, we have to take treatment decisions based upon minimal lymph node involvement, with a clinical significance still poorly understood. Second, for the large tumors, potentially with lymph node involvement, we have to deal with tumor and lymph node under staging, after induction chemotherapy. We have to learn how to evaluate accurately those new parameters to treat the best way our patients.

Predictive value of HER-2 and Topoisomerase IIα in response to primary doxorubicin in breast cancer

AIM

To study the predictive role of HER-2 and Topoisomerase IIalpha (TOP2A) in response to primary doxorubicin.

METHODS

Two hundred and thirty-two patients with operable breast cancer were treated with doxorubicin prior to surgery. ER, PgR, grade, Ki-67 and HER-2 status were prospectively assessed. HER-2 overexpression was evaluated with immunohistochemistry; positive cases were then studied for gene copy number of HER-2, TOP2A and chromosome 17 centromere by chromogenic in situ hybridisation. Clinical response was assessed by mammography. Pathological response was evaluated as the percentage of tumour replaced by changes due to chemotherapy.

RESULTS

HER-2 amplification was associated with clinical response (p=0.04). ER and PgR negativity, high Ki-67 and HER-2 amplification significantly correlated to pathological response (p<0.05). Tumours with coamplification of HER-2 and TOP2A showed a higher percentage of pathological changes (p=0.6). However, in the multivariate analysis for complete pathological response, ER negativity and high Ki-67 index were the only parameters that maintained statistical significance.

CONCLUSION

HER2 and Topoisomerase IIalpha amplification failed to show an association with pathological response to doxorubicin, whereas ER negativity and a high proliferation rate were predictive of complete pathological response to this regime.

Differences in Sentinel Lymph Node Pathology Protocols Lead to Differences in Surgical Strategy in Breast Cancer Patients

BACKGROUND

Internationally, there is no consensus on the pathology protocol to be used to examine the sentinel lymph node (SN). At present, therefore, various hospitals use different SN pathology protocols of which the effect has not been fully elucidated. We hypothesized that differences between hospitals in SN pathology protocols affect subsequent surgical treatment strategies.

METHODS

Patients from four hospitals (A-D) were prospectively registered when they underwent an SN biopsy. In hospitals A, B, and C, three levels of the SN were examined pathologically, whereas in hospital D, at least seven additional levels were examined. In the absence of apparent metastases with hematoxylin and eosin examination, immunohistochemical examination was performed in all four hospitals.

RESULTS

In total, 541 eligible patients were included. In hospital D, more patients were diagnosed with a positive SN (P < .001) as compared with hospitals A, B, and C, mainly because of increased detection of isolated tumor cells. This led to more completion axillary lymph node dissections in hospital D (66.3% of patients (P < .0001), compared with 29.0% in hospitals A, B, and C combined). Positive non-SNs were detected in 13.9% of patients in hospital D, compared with 9.7% in hospitals A, B, and C (P = .70). That is, in 52.4% of patients in hospital D, a negative completion axillary lymph node dissection was performed, compared with 19.3% of patients in hospitals A, B, and C combined.

CONCLUSIONS

Differences in SN pathology protocols between hospitals do have a substantial effect on SN findings and subsequent surgical treatment strategies. Whether ultrastaging and, thus, additional surgery can offer better survival remains to be determined.

Response to neoadjuvant chemotherapy in lobular and ductal breast carcinomas: a retrospective study on 860 patients from one institution

BACKGROUND

We compared the impact of neoadjuvant chemotherapy on pathologic response and outcome in operable invasive lobular breast carcinoma (ILC) and invasive ductal breast carcinoma (IDC).

PATIENTS AND METHODS

We extracted from our database all patients with pure invasive lobular (n=118, 14%) or pure invasive ductal carcinomas (n=742, 86%). Their treatment included neoadjuvant chemotherapy, adapted surgery, radiotherapy and adjuvant hormonal treatment.

RESULTS

Compared with IDC, ILC presented with larger tumors (T3: 38.1% versus 21.4%, P=0.0007), more N0 nodes status (55.9% versus 43.3%, P=0.01), less inflammatory tumors (5.9% versus 11.8%, P=0.01), more hormone receptor positivity (65.5% versus 38.8%), lower histological grade (P<0.0001). Final surgery was a mastectomy in 70% of patients with ILC (34% were reoperated after initial partial mastectomy) and in 52% of IDC after 8% of reoperation (P=0.006). A pathological complete response (pCR) was achieved in 1% of ILC and 9% of IDC (P=0.002). The outcome at 60 months was significantly better for ILC, but histologic type was not an independent factor for survival in multivariate analysis.

CONCLUSIONS

ILC appeared less responsive to chemotherapy but presented a better outcome than IDC. While new information on biological features of ILC is needed, we consider that neoadjuvant endocrine therapy in hormone receptor-positive ILC may be a more adapted approach than neoadjuvant chemotherapy.

Tumour response to preoperative anthracycline-based chemotherapy in operable breast cancer: the predictive role of p53 expression

The aim of this retrospective study was to identify markers capable of predicting pathological complete (pCR) and overall clinical tumour response to preoperative anthracycline-based chemotherapy and clinical outcome in women with operable breast cancer. Therefore, we used the pre-treatment core biopsies from 107 patients who were enrolled in the EORTC trial 10902 to analyse tumour characteristics and the oncogenic markers Bcl-2, p53, ER, PgR, HER2, and p21. Median follow-up was 7 years (95% confidence interval [CI], 6.89-7.45). pCR was seen in seven patients (6.5%) and was associated with improved overall survival (hazards ratio, 0.39; 95% CI, 0.05-2.56; P = 0.30). In multivariate logistic regression analysis, pCR was independently predicted by p53 overexpression estimated by immunohistochemistry (odds ratio [OR], 16.83; 95% CI, 1.78-159.33; P = 0.01). Fifty-eight patients showed clinical tumour response (>50% decrease in tumour size), however responders experienced no benefit in clinical outcome. Clinical tumour response was independently predicted by p53 overexpression (OR, 5.57; 95% CI, 1.58-19.65; P = 0.008) and small clinical tumour size (OR, 10.26; 95% CI, 2.01-52.48; P = 0.005). In multivariate Cox regression analysis, negative pathological lymph node status, low tumour grade and use of tamoxifen showed improved overall survival. In conclusion, our data suggest p53 expression is of predictive significance in anthracycline-containing chemotherapeutic regimens.

Neoadjuvant systemic therapy for breast cancer: an overview and review of recent clinical trials

Neoadjuvant chemotherapy (NAC) is long established as part of the multi-modality management of locally advanced breast cancer or inflammatory breast cancer, leading to significantly improved outcome. Numerous recent studies have compared the use of anthracycline-based NAC with adjuvant chemotherapy in earlier-stage disease, and have shown equivalent disease-free and overall survival rates with increased breast conservation rates. These studies have also shown that a pathological complete response after NAC is associated with improved long-term outcome. More recently, the taxanes have been introduced into clinical trials of NAC with increased overall and pCR rates. However, there is no evidence that the addition of taxanes to neoadjuvant anthracycline-based chemotherapy significantly improves long-term disease free survival or overall survival. This paper reviews these trials, as well as trials of dose-dense and trastuzumab-containing NAC regimens. The review discusses the potential for NAC to replace prolonged adjuvant trials in the assessment of new therapeutic agents (using pathological complete response as a surrogate for long-term outcome), to be used as an in vivo chemosensitivity assay to guide further treatment, and to identify molecular markers that correlate with tumour sensitivity or resistance to chemotherapeutic agents so that the treatment of patients can be individualised.

Survival in cervix cancer patients treated with radiotherapy followed by radical surgery

AIM

To determine the incidence and predictive value of residual disease in the hysterectomy specimens of cervical cancer patients treated with primary radiotherapy, with or without chemotherapy, followed by surgery and to determine whether pathologically confirmed residual disease is a surrogate marker of outcome.

METHODS

The medical records of patients treated for stage IB/II carcinoma of the cervix in a single institution between 1985 and 2000 were retrospectively analysed into two different groups, depending on whether they had received radiotherapy or concurrent chemo-radiotherapy. Six to 8 weeks after irradiation, all patients underwent radical or extrafascial hysterectomy and pelvic and para-aortic lymphadenectomy.

RESULTS

A total of 403 patients were included in the study (360 in the radiotherapy only group and 43 in the chemo-radiotherapy group). One hundred and seventy-eight patients had residual disease on hysterectomy specimens in the radiotherapy group. Considering only the stages IB2 and II, 126 (52%) and 16 (37%) patients had residual disease on hysterectomy specimens in the radiotherapy group and in the chemo-radiotherapy group, respectively (P=0.08). Residual disease was associated with pelvic and para-aortic nodal metastases. The 5-year local control and overall survival rates were 88 and 86%, respectively, in the patients with complete pathologic response and 73 and 62%, respectively, in the patients with residual disease (P<0.001). In multivariate analysis, FIGO stage, residual disease, and pathologic nodal involvement were independent predictive factors of both local recurrence and overall survival.

CONCLUSION

Pathologically confirmed residual disease on hysterectomy specimen is an independent and strong predictive factor of both local recurrence and overall survival.

Increased Feasibility of Weekly Epirubicin and Paclitaxel as Neoadjuvant Chemotherapy for Locally Advanced Breast Carcinoma

BACKGROUND

Primary systemic therapy (PST) with a combination of epirubicin and paclitaxel achieves high response rates in locally advanced breast cancer (LABC), but considerable toxicity occurs and the patient's compliance is poor. In this open-label phase II trial toxicity of a weekly administration schedule was evaluated.

PATIENTS AND METHODS

On days 1 and 8 of each 3-week cycle, 45 patients with non-inflammatory breast cancer received epirubicin (35 mg/m(2), intravenous bolus) followed by paclitaxel (80 mg/m(2) in 500 ml of normal saline infused over 3 h) for 3 cycles. Surgery was done 2 weeks after primary chemotherapy, followed by another 6 cycles of adjuvant CEF (cyclophosphamide 500 mg/m(2), epirubicin 70 mg/m(2), 5-fluorouracil 500 mg/m(2)) chemotherapy.

RESULTS

The median tumor size before and after PST was 6.0 and 2.0 cm, respectively. The clinical response rate was 96%, including 24% complete remission; 5 patients (11%) achieved pathologically complete response (pCR) including 3 patients with carcinoma in situ. Only 5 (11%) patients underwent breast conserving surgery although there were 15 patients suitable. Axillary nodes were negative in 16 (36%) of the 45 patients. Febrile neutropenia was found in 1 patient. There was no severe cardiac toxicity or serious adverse events.

CONCLUSIONS

PST with weekly epirubicin and paclitaxel was an effective and well-tolerated combination for LABC, although only few patients underwent breast conserving surgery.

Weekly docetaxel/carboplatin as primary systemic therapy for HER2-negative locally advanced breast cancer

To evaluate the effectiveness and safety of weekly docetaxel/carboplatin as primary systemic therapy (PST) for locally advanced breast cancer, we conducted a phase II study. Forty-four patients with HER2-negative locally advanced or inflammatory breast cancer (IBC) received docetaxel 35 mg/m(2) and carboplatin to an area under the curve of 2 mg/mL/min for 3 of 4 weeks over 16 weeks. After completion of PST, patients had breast surgery and then received 4 cycles of adjuvant cyclophosphamide/doxorubicin, standard radiation therapy, and, for hormone receptorpositive tumors, tamoxifen. The mean tumor size was 9.3 cm (range, 5-24 cm). Thirty-seven patients (85%) had palpable lymph nodes; 13 patients (30%) had matted or fixed nodes (N2). Eight patients had IBC. There were 11 clinical complete responses (25%) and 29 clinical partial responses (66%), resulting in 40 objective responses (91% [95% CI, 78%-96%]). Invasive disease disappeared (pathologic complete response) from the breast and axilla in 6 patients (14% [95% CI, 5%-27%]) and from the axilla in 17 patients (39% [95% CI, 24%-55%]). The only significant adverse hematologic event was grade 3 neutropenia in 4 patients (9%). The most common adverse nonhematologic events were fatigue (84% of patients) and alopecia (84%), which were usually grade 1/2. Weekly docetaxel/carboplatin appears to be active and feasible as PST in patients with large breast tumors.

[Association of taxanes and radiotherapy: preclinical and clinical studies]

Taxanes (paclitaxel and docetaxel) stabilized microtubules against depolymerization, and inhibit their function. Their radiosensitizing properties have been discovered more than 10 years ago; they synchronized tumor cells in G2/M phase, the most radiosensitive portion of the cell cycle. Other radiosensitizing mechanisms have been also discussed, as reoxygenation, promotion of radio-apoptosis and antiangiogenic cooperation. Many phase I and II studies have been performed, essentially in bronchus and head and neck carcinomas. In lung cancer, paclitaxel was delivered weekly at a dose of 60 mg/m2. Many studies combined cisplatin or carboplatin with paclitaxel, demonstrating that this combination is feasible and efficient. Only one phase III trial was reported; after two cycles of chemotherapy for inoperable lung cancers, radiotherapy was delivered, with or without paclitaxel radiosensitization: a benefit in disease-free survival was observed for the combination arm. In head and neck carcinomas, conomitant association of cisplatin, paclitaxel and radiation was feasible and showed promising results. Clinical trials with docetaxel are in progress.

[Neoadjuvant therapy of breast cancer]

Whereas in the past primary systemic therapy (PST) was rather used for other tumor entities or was limited to the use in inoperable breast cancer, treatment of operable stages is being increasingly investigated. After the proof of equivalency between PST and adjuvant chemotherapy, numerous trials have been conducted. PST enables testing of in vivo chemosensitivity; thus, treatment can be monitored by tumor response. Insufficient responders can be switched to non-cross-resistant concepts to avoid administration of ineffective drugs and try to achieve improvement of survival for these patients. The reduction of tumor size not only increases the rate of breast-conserving therapy, but has predictive value for the further course of the disease. Especially pathohistological complete remission is a good surrogate marker for improved survival and the goal of modern protocols in the preoperative setting. Actively recruiting trials (e.g. trials of the AGO PREPARE and TECHNO) integrate modern concepts of treatment like dose-dense, dose-intensified, sequential therapy and tumor targeting with trastuzumab in PST. Eligible patients should be recruited in ongoing trials to further elucidate the role of PST in primary breast cancer. Evaluation of predictive factors and correlation of therapy response to the genetic profile of the tumor with modern technologies will allow improved selection of patients with increasingly tailored therapy.

Primary chemotherapy for breast cancer: the evidence and the future

The first generation of randomised trials assessing the role of primary chemotherapy in breast cancer has failed to demonstrate the expected survival benefit. However, it has established the role of this treatment in 'downstaging' tumours of patients with locally advanced disease and, consequently, in improving breast conservation rates. Also, a number of surrogates of outcome have been identified, which will hopefully lead to earlier results in breast cancer clinical trials. Encouraging results have also been reported in trials investigating a number of novel approaches.

T3 disease at presentation or pathologic involvement of four or more lymph nodes predict for locoregional recurrence in stage II breast cancer treated with neoadjuvant chemotherapy and mastectomy without radiotherapy

PURPOSE

To help define the clinical and pathologic predictors of locoregional recurrence (LRR) in breast cancer patients treated with neoadjuvant chemotherapy and mastectomy without radiotherapy for early-stage disease.

METHODS AND MATERIALS

We retrospectively reviewed the outcomes of all 132 patients with Stage I or II breast cancer treated in prospective institutional trials with neoadjuvant chemotherapy and mastectomy without radiotherapy between 1974 and 2001. The clinical stage (American Joint Committee on Cancer 1988) at diagnosis was I in 5%, IIA in 46%, and IIB in 49% of patients. The median age at diagnosis was 49 years. All patients were treated with either a doxorubicin-based neoadjuvant regimen or single-agent paclitaxel. The total LRR rates were calculated by the Kaplan-Meier method, and comparisons were made with two-sided log-rank tests. The median follow-up was 46 months.

RESULTS

The actuarial LRR rate at both 5 and 10 years was 10%. Factors that correlated positively with LRR included clinical Stage T3N0 (p = 0.0057), four or more positive lymph nodes at surgery (p = 0.0001), age < or =40 years at diagnosis (p = 0.0001), and no use of tamoxifen. In the patients who did not receive tamoxifen, estrogen receptor-positive disease correlated positively with LRR (p = 0.0067). The 5-year LRR rate for the 42 patients with clinical Stage T1 or T2 disease and one to three positive lymph nodes at surgery was 5% (only two events).

CONCLUSIONS

For patients with clinical Stage II breast cancer, T3 primary disease, four or more positive lymph nodes after chemotherapy, and age < or =40 years old predicted for LRR. For most patients with clinical T1 or T2 disease and one to three positive lymph nodes, the 5-year risk for LRR was low, and the routine inclusion of postmastectomy radiotherapy does not appear to be justified.

Current issues in the surgical management of breast cancer: a review of abstracts from the 2002 San Antonio Breast Cancer Symposium, the 2003 Society of Surgical Oncology annual meeting, and the 2003 American Society of Clinical Oncology meeting

Three areas of development in the surgical management of breast cancer received significant attention in 2003--breast-conserving surgery, sentinel lymph node (SLN) biopsy, and ductal lavage. Provocative investigations focusing on these controversial aspects of surgical care were presented at major national oncology meetings throughout the year. The recently published 20-year updates by the National Surgical Adjuvant Breast and Bowel Project (NSABP) and the Italian National Cancer Institute confirm the survival equivalence of breast-conserving surgery and mastectomy in early stage disease. Data reveal, however, that this strategy is underutilized in the United States when compared with other countries. A meta-analysis of close to 70 published trials on the use of SLN biopsy has revealed an overall SLN identification rate of greater than 90%, with a false-negative rate of 8.4%. Two major controversies remain to be resolved: Is there a subset of sentinel node-positive patients who may safely avoid complete axillary lymph node dissection? What is the best way integrate lymphatic mapping into neoadjuvant chemotherapy protocols? The strength of ductal lavage as a risk assessment adjunct is related to the ability to detect cellular atypia, a feature associated with a three- to fivefold increased risk for breast cancer. This technique continues to be rigorously evaluated in a number of ongoing studies.

The poor responsiveness of infiltrating lobular breast carcinomas to neoadjuvant chemotherapy can be explained by their biological profile

The aim of this study was to determine the chemosensitivity of infiltrating lobular breast carcinoma (ILC) in comparison with infiltrating ductal carcinoma (IDC). Between 1987 and 1995, 457 patients with invasive T2>3 cm-T4 breast carcinomas were treated with primary chemotherapy (CT), surgery, radiation therapy. Clinical response, the possibility of breast preservation, pathological response and survival were evaluated according to the histological type. In order to evaluate the biological differences between ILC and IDC patients and their implication with regard to tumour chemosensitivity, additional immunohistochemical stainings (oestrogen receptor (ER), Bcl2, p53, c-erbB-2 and Ki67) were performed on 129 pretherapeutical specimens. 38 (8.3%) ILC were diagnosed by core needle biopsy before CT. ILC was an independent predictor of a poor clinical response (P=0.02) and ineligibility for breast-conserving surgery after neoadjuvant chemotherapy (P=0.03). Histological and biological factors predicting a poor response to CT (histological grade, ER, Ki67 and p53 status) were more frequent in ILC than in IDC patients. After a median follow-up of 98 months (range: 3-166), the low chemosensitivity of ILC did not result in a survival disadvantage. Our results demonstrate that ILC achieved a lower response to CT than IDC because of their immunohistochemical profile. Preoperative CT did not allow a high rate of conservative treatment for ILC and therefore the use of neoadjuvant CT for ILC patients should be questioned.

Phase II trial combining docetaxel and doxorubicin as neoadjuvant chemotherapy in patients with operable breast cancer

BACKGROUND

This study was conducted to assess the antitumour activity of docetaxel in combination with doxorubicin for neoadjuvant therapy of patients with breast cancer.

PATIENTS AND METHODS

Forty-eight women were treated with intravenous doxorubicin 50 mg/m(2) over 15 min followed by a 1-h infusion of docetaxel 75 mg/m(2) every 3 weeks for six cycles. Dexamethasone or prednisolone premedication was allowed. Granulocyte colony-stimulating factor was not allowed as primary prophylaxis. The primary end point was the pathologically documented complete response rate (pathological response).

RESULTS

The mean relative dose intensity calculated for four or more cycles was 0.99 for doxorubicin and 0.99 for docetaxel. Overall, the pathological response rate was 13%. There were 11 complete and 29 partial clinical responses for an overall response rate of 85% [95% confidence interval (CI) 75% to 95%] in the evaluable population (n = 47). Disease-free and overall survival rates were 85% (95% CI 71% to 94%) and 96% (95% CI 85% to 99%), respectively, after a median follow-up of 36.6 months. Grade 3/4 neutropenia was observed in 65% of patients and 17% reported grade 4 febrile neutropenia.

CONCLUSIONS

Docetaxel and doxorubicin is an effective and well-tolerated combination in the neoadjuvant therapy of breast cancer. Future controlled trials are warranted to investigate the best schedules and to correlate response with biological factors.

Sentinel node biopsy prior to neoadjuvant chemotherapy

BACKGROUND

Several studies have explored sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy, but false negative rates and the loss of pretreatment nodal staging are limitations. Sentinel lymph node biopsy prior to induction chemotherapy may address both.

METHODS

Sentinel lymph node biopsy was performed in clinically node negative patients prior to initiating chemotherapy. Standard level I/II axillary lymph node dissection (ALND) was performed at the time of surgery in those patients who had metastases in the sentinel lymph node (SLN).

RESULTS

Twenty-five patients had 26 SLNB prior to the initiation of chemotherapy. The SLN was identified in all cases (100%). Twelve patients (48%) were found to be node negative and did not require axillary node dissection after chemotherapy. Of the patients who were SLN positive and underwent completion ALND, residual nodal disease was identified in 60%. There were no surgical complications or delay of chemotherapy.

CONCLUSIONS

Sentinel lymph node biopsy prior to neoadjuvant chemotherapy can avoid the morbidity of ALND without compromising the accuracy of axillary staging. It allows for identification of node positive patients subsequently rendered disease free in the regional nodes, which can assist in planning additional chemotherapy or radiation.

Is there still a role for neoadjuvant therapy in breast cancer?

The role of neoadjuvant chemotherapy in locally advanced breast cancer is firmly established. There is now also an emerging role for neoadjuvant systemic therapy in the treatment of operable breast cancer. There is good evidence that the chances of breast conserving surgery can be increased with this approach and results of randomised studies indicate that survival is at least as good with neoadjuvant as with adjuvant chemotherapy. Similar clinical data are emerging with neoadjuvant endocrine therapy. For the future, there are important potential advantages in having an in vivo measure of chemosensitivity rather than blindly treating micrometastatic disease in the adjuvant setting. Clinical response to neoadjuvant treatment, and in particular complete pathological response, are predictors of subsequent outcome. Pathological involvement of axillary nodes following neoadjuvant therapy portends a poor prognosis. The potential for biological surrogate markers of response to predict for long-term outcome may allow individualisation of systemic treatment and the rapid assessment of new drugs in early breast cancer.

Mast cell density and the context of clinicopathological parameters and expression of p185, estrogen receptor, and proliferating cell nuclear antigen in gastric carcinoma

AIM: To investigate the relationship between the mast cell density (MCD) and the context of clinicopathological parameters and expression of p185, estrogen receptor (ER), and proliferating cell nuclear antigen (PCNA) in gastric carcinoma.

METHODS: Mast cell, p185, ER, and PCNA were detected using immunohistochemical S-P labeling method. Mast cell was counted in tissue of gastric carcinoma and regional lymph nodes respectively, and involved lymph nodes (ILN) were examined as usual.

RESULTS: MCD was significantly related to both age and depth of penetration (χ² = 4.688,P < 0.05 for age and χ² = 9.350, P < 0.01 for depth of penetration) between MCD > 21/0.03 mm² and MCD ≤ 21/0.03 mm² in 100 patients; MCD in 1-6 ILN group patients was significantly higher than that in 7-15 ILN or > 15 ILN group patients (u = 6.881, 8.055, P < 0.01); There were significant differences intergroup in positive expression rate of p185, ER and PCNA between MCD > 21/ 0.03 mm² and MCD ≤ 21/0.03 mm² in 100 patients.

CONCLUSION: Mast cell may have effect on inhibiting invasive growth of tumor, especially in the aged patients; The number of mast cells, in certain degree, may predicate the number of involved lymph nodes, which is valuable for assessment of prognosis; MCD was related to the expression of p185, ER, and PCNA in gastric carcinoma. It suggests that mast cell accumulation may inhibit the proliferation and the dissemination of the gastric carcinoma.