Inflammatory breast cancer outcome with epirubicin-based induction and maintenance chemotherapy: ten-year results from the French Adjuvant Study Group GETIS 02 Trial

Pathological complete response of adding targeted therapy to neoadjuvant chemotherapy for inflammatory breast cancer: A systematic review

Background

The current use of targeted therapy plus neoadjuvant chemotherapy for inflammatory breast cancer (IBC) is based on data extrapolated from studies in non-IBC. We conducted a systematic review to determine whether neoadjuvant chemotherapy plus targeted therapy results in a higher pathologic complete response (pCR) rate than neoadjuvant chemotherapy alone in patients with IBC.

Method and findings

This systematic review was registered in the PROSPERO register with registration number CRD42018089465. We searched MEDLINE & PubMed, EMBASE, and EBSCO from December 1998 through July 2020. All English-language clinical studies, both randomized and non-randomized, that evaluated neoadjuvant systemic treatment with or without targeted therapy before definitive surgery and reported the pCR results of IBC patients. First reviewer extracted data and assessed the risk of bias using the Risk of Bias In Non-randomized Studies of Interventions tool. Second reviewer confirmed the accuracy. Studies were divided into 3 groups according to systemic treatment: chemotherapy with targeted therapy, chemotherapy alone, and high-dose chemotherapy with hematopoietic stem cell support (HSCS). Of 995 screened studies, 23 with 1,269 IBC patients met the inclusion criteria. For each of the 3 groups of studies, we computed a weighted average of the pCR rates across all studies with confidence interval (CI). The weighted averages (95% CIs) were as follows: chemotherapy with targeted therapy, 31.6% (26.4%-37.3%), chemotherapy alone, 13.0% (10.3%-16.2%), and high-dose chemotherapy with HSCS, 23.0% (18.7%-27.7%). The high pCR by targeted therapy group came from anti-HER2 therapy, 54.4% (44.3%-64.0%). Key limitations of this study included no randomized clinical studies that included only IBC patients.

Conclusion

Neoadjuvant chemotherapy plus targeted therapy is more effective than neoadjuvant chemotherapy alone for IBC patients. These findings support current IBC standard practice in particular the use of anti-HER2 targeted therapy.

COMPARATIVE CHARACTERISTICS OF THE METHODS OF CHEMODRUGS ADMINISTRATION IN THE TREATMENT OF PATIENTS WITH LOCALLY-ADVANCED BREAST CANCER

The development of new methods of treating patients with breast cancer (BC) causes no doubts at anyone at present moment. The statistical data testify to steady growth of BC sickness rate during recent 20 years without tendency to stabilization The special attention is paid to the development of new methods of treating BC patients (regional forms of disease) with unfavorable factors for forecast of tumor growth. The presented methods of treatment of patients with locally-advanced breast cancer consist in giving complex treatment using two simultaneous ways of administration of chemodrugs - selective intra-arterial and endolymphatic in combination with a systemic one. The results obtained demonstrated greater efficacy of treatment with combinations of selective intra-arterial chemotherapy with a systemic one compared with endolymphatic chemotherapy in combination with the systemic one for the treatment of this disease. Materials and methods. The present study was based on the data of 285 patients with locally-advanced forms of breast cancer HER/2-neu positive and basal-like biological subtypes, with the stages T4N0-2M0, the treatment was given in Donetsk regional antitumor center and Odessa University Clinic in 2000-2014. During the research for an adequate analysis of the results of treatment by the technique under consideration there were formed two groups of patients. The first investigated group included 221 patients, in 168 patients were diagnosed HER/2-neu positive tumors in immunohistochemical conclusion and 53 patients had basal-like biological subtype of the tumor. The program of the comprehensive treatment of patients in this group included the internal thoracic artery catheterization through the upper epigastric artery, two or three cycles of SIAPCT in combination with intravenous one with an interval of 21 days, evaluation of the effect of radiation therapy (RT) on the breast and zone of the regional lymph outflow in the static mode SFD- 2-2.5 Gy, CFD- 40 Gy, the interval, estimation of the effect. Mastectomy in the patients of the investigated group was performed only when there was a complete or partial tumor response (136 surgeries in a radical scope). Courses of intraarterial PCT were given in continuous long-term infusion (4 hours) by the scheme CMF, CAF or CAMF. Taking into account the possibility of local complications against the background of administration of some chemotherapeutic agents (most often - doxorubicin), half of the drug dose was administered intravenously. The total course doses of chemodrugs were calculated according to BSA criteria. The control group included 64 patients, 45 were identified to have HER/2-neu positive and 19 basal-like subtypes of breast cancer. The program of comprehensive treatment of the patients of this group includes endolymphatic chemotherapy according to the method developed by Donetsk regional antitumor center. As the main method of administration of chemodrugs in the lymphatic system there was used infusion introduction with the help of the system for intravenous drip, infusion rate was 0.3-0.5 ml/min that allowed us to exclude the possibility of extravasation of the chemodrug solution. The course dose of the drug was administered endolymphatically within 5-7 days. At the interval of 21 days two or three courses of ELPHT were given combined with the intravenous administration of anthracyclines (at the end of each cycle the catheter was removed, the catheterization was performed repeatedly). Then the effectiveness of the treatment by the criteria of RECIST was evaluated. Radiation therapy (RT) to the breast and area of the regional lymph outflow was given in a static mode SFD- 2-2.5 Gy, CFD- 40 Gy followed by evaluation of the effect. Mastectomy in the patients of the control group was performed only at the complete or partial tumor response (36 operations in a radical scope). Courses of endolymphatic PCT were given by the continuous long-term infusion (up to 8 hours) scheme of CMF, CAF or CAMF. Taking into account the possibility of local complications against the background of introduction of some chemotherapeutic agents, intercalator doxorubicin was administered intravenously, and antimetabolites and alkylating agents (methotrexate, 5-fluorouracil and cyclophosphamide) in all schemes were introduced endolymphatically. Results. The average life expectancy of patients of the investigated group was 3.43 ± 0.18 years, while in the control group it was 2.82 ± 0.3 that significantly exceeded the statistical data of domestic and foreign authors. Indices of total 3-year survival rate of patients of the investigated group were 59.9 ±4.5% and 5-year- - 43.1 ±5.5 months. In the control group indices of cumulative 3- and 5-year survival rates were significantly lower - 37.8% ± 6.6 and 25.2 ± 7.0%months respectively. Conclusions. 1. The results of complex treatment of locally-advanced breast cancer with unfavorable prognostic factors of tumor growth by the developed technique by using a combination of selective intra-arterial injection and intravenous chemotherapy in a pool of the internal thoracic artery in combination with radiation and hormonal therapy exceed the results of standard treatment programs for the patients with locally-advanced breast cancer with performing mastectomy and systemic chemotherapy. 2. The method developed by the authors can be recommended for widespread use in these patients.

THE METHOD OF TREATMENT OF PATIENTS WITH LOCALLY-ADVANCED BREAST CANCER

A method of care of patients with locally-advanced breast cancer consisting of using regional selective intraarterial chemotherapy in the schedule of the complex (palliative) treatment is presented. Results of treatment showed an advantage in comparison with the application of traditional methods of the breast cancer treatment. The methodology on intra-arterial introduction of chemotherapeutic agents developed at Donetsk Regional Antitumoral Center and University clinic of Odessa showed its undisputable contribution into development of modern oncology through decrease of primary tumoral locus, transition from inoperable state into the state at which it is possible to perform the radical volume of surgical interference to patient. The special attention is paid to development of new methods of treating BC patients (regional forms of disease) with unfavorable factors for forecast of tumor growth.

Prophylactic antibiotics or G(M)-CSF for the prevention of infections and improvement of survival in cancer patients receiving myelotoxic chemotherapy

BACKGROUND

Febrile neutropenia (FN) and other infectious complications are some of the most serious treatment-related toxicities of chemotherapy for cancer, with a mortality rate of 2% to 21%. The two main types of prophylactic regimens are granulocyte (macrophage) colony-stimulating factors (G(M)-CSF) and antibiotics, frequently quinolones or cotrimoxazole. Current guidelines recommend the use of colony-stimulating factors when the risk of febrile neutropenia is above 20%, but they do not mention the use of antibiotics. However, both regimens have been shown to reduce the incidence of infections. Since no systematic review has compared the two regimens, a systematic review was undertaken.

OBJECTIVES

To compare the efficacy and safety of G(M)-CSF compared to antibiotics in cancer patients receiving myelotoxic chemotherapy.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE, databases of ongoing trials, and conference proceedings of the American Society of Clinical Oncology and the American Society of Hematology (1980 to December 2015). We planned to include both full-text and abstract publications. Two review authors independently screened search results.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing prophylaxis with G(M)-CSF versus antibiotics for the prevention of infection in cancer patients of all ages receiving chemotherapy. All study arms had to receive identical chemotherapy regimes and other supportive care. We included full-text, abstracts, and unpublished data if sufficient information on study design, participant characteristics, interventions and outcomes was available. We excluded cross-over trials, quasi-randomised trials and post-hoc retrospective trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the results of the search strategies, extracted data, assessed risk of bias, and analysed data according to standard Cochrane methods. We did final interpretation together with an experienced clinician.

MAIN RESULTS

In this updated review, we included no new randomised controlled trials. We included two trials in the review, one with 40 breast cancer patients receiving high-dose chemotherapy and G-CSF compared to antibiotics, a second one evaluating 155 patients with small-cell lung cancer receiving GM-CSF or antibiotics.We judge the overall risk of bias as high in the G-CSF trial, as neither patients nor physicians were blinded and not all included patients were analysed as randomised (7 out of 40 patients). We considered the overall risk of bias in the GM-CSF to be moderate, because of the risk of performance bias (neither patients nor personnel were blinded), but low risk of selection and attrition bias.For the trial comparing G-CSF to antibiotics, all cause mortality was not reported. There was no evidence of a difference for infection-related mortality, with zero events in each arm. Microbiologically or clinically documented infections, severe infections, quality of life, and adverse events were not reported. There was no evidence of a difference in frequency of febrile neutropenia (risk ratio (RR) 1.22; 95% confidence interval (CI) 0.53 to 2.84). The quality of the evidence for the two reported outcomes, infection-related mortality and frequency of febrile neutropenia, was very low, due to the low number of patients evaluated (high imprecision) and the high risk of bias.There was no evidence of a difference in terms of median survival time in the trial comparing GM-CSF and antibiotics. Two-year survival times were 6% (0 to 12%) in both arms (high imprecision, low quality of evidence). There were four toxic deaths in the GM-CSF arm and three in the antibiotics arm (3.8%), without evidence of a difference (RR 1.32; 95% CI 0.30 to 5.69; P = 0.71; low quality of evidence). There were 28% grade III or IV infections in the GM-CSF arm and 18% in the antibiotics arm, without any evidence of a difference (RR 1.55; 95% CI 0.86 to 2.80; P = 0.15, low quality of evidence). There were 5 episodes out of 360 cycles of grade IV infections in the GM-CSF arm and 3 episodes out of 334 cycles in the cotrimoxazole arm (0.8%), with no evidence of a difference (RR 1.55; 95% CI 0.37 to 6.42; P = 0.55; low quality of evidence). There was no significant difference between the two arms for non-haematological toxicities like diarrhoea, stomatitis, infections, neurologic, respiratory, or cardiac adverse events. Grade III and IV thrombopenia occurred significantly more frequently in the GM-CSF arm (60.8%) compared to the antibiotics arm (28.9%); (RR 2.10; 95% CI 1.41 to 3.12; P = 0.0002; low quality of evidence). Neither infection-related mortality, incidence of febrile neutropenia, nor quality of life were reported in this trial.

AUTHORS' CONCLUSIONS

As we only found two small trials with 195 patients altogether, no conclusion for clinical practice is possible. More trials are necessary to assess the benefits and harms of G(M)-CSF compared to antibiotics for infection prevention in cancer patients receiving chemotherapy.

Primary prophylactic colony-stimulating factors for the prevention of chemotherapy-induced febrile neutropenia in breast cancer patients

BACKGROUND

High-dose or dose-intensive cytotoxic chemotherapy often causes myelosuppression and severe neutropenia among cancer patients. Severe neutropenia accompanied by fever, named febrile neutropenia (FN), is the most serious manifestation of neutropenia usually requiring hospitalization and intravenous antibiotics. FN and neutropenia can lead to chemotherapy treatment delays or dose reductions, which potentially compromises the effectiveness of cancer treatment and prospects for a cure. Granulocyte-macrophage (GM) and granulocyte colony-stimulating factors (G-CSFs) are administered during chemotherapy in order to prevent or reduce the incidence or the duration of FN and neutropenia.

OBJECTIVES

To assess the effect of prophylactic colony-stimulating factors (CSFs) in reducing the incidence and duration of FN, and all-cause and infection-related mortality during chemotherapy in patients with breast cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, HEALTHSTAR, International Health Technology Assessment, SOMED, AMED and BIOSIS up to 8 August 2011. We also searched three Chinese databases (VIP, CNKI, CBM), the metaRegister of Controlled Trials, ClinicalTrials.gov, the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP) and OpenGrey.eu up to August 2011.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing CSFs (any dose) with placebo or no treatment in patients with breast cancer at any stage, at risk of developing FN while undergoing any type of chemotherapy.

DATA COLLECTION AND ANALYSIS

We used pooled risk ratios (RR) with 95% confidence intervals (CIs) for binary outcomes. At least two review authors independently extracted data and assessed the risk of bias of the included studies. Trial authors were contacted for further details when information was unclear.

MAIN RESULTS

We included eight RCTs involving 2156 participants with different stages of breast cancer and chemotherapy regimens. The trials were carried out between 1995 and 2008 and judged as being at least at moderate risk of bias. The strength of the evidence was weak for the majority of outcomes, which was mostly because of the small numbers of evaluable patients, varying definitions, as well as unclear measurements of the trials' outcomes and uncertain influences of supportive treatments on them. In most trials, the chemotherapy regimens had a risk of FN that was below the threshold at which current guidelines recommend routine primary prophylaxis with CSFs. Using CSFs significantly reduced the proportion of patients with FN (RR 0.27; 95% CI 0.11 to 0.70; number needed to treat for an additional beneficial outcome (NNTB) 12) but there was substantial heterogeneity which can be explained by possible differential effects of G-CSFs and GM-CSFs and different definitions of FN. A significant reduction in early mortality was observed in CSF-treated patients compared to placebo or no treatment (RR 0.32; 95% CI 0.13 to 0.77; NNTB 79). This finding was based on 23 fatal events in 2143 patients; wherein 19 of these 23 events occurred in one study and 17 events were attributed to progression of the disease by the study authors. For infection-related mortality, there were no significant differences between CSF and control groups (RR 0.14; 95% CI 0.02 to 1.29). In CSF-treated patients, the risk for hospitalization was significantly reduced (RR 0.14; 95% CI 0.06 to 0.30; NNTB 13), as well as the use of intravenous antibiotics (RR 0.35; 95% CI 0.22 to 0.55; NNTB 18). The risks of severe neutropenia, infection or not maintaining the scheduled dose of chemotherapy did not differ between CSF-treated and control groups. CSFs frequently led to bone pain (RR 5.88; 95% CI 2.54 to 13.60; number needed to treat for an additional harmful outcome (NNTH) 3) and injection-site reactions (RR 3.59; 95% CI 2.33 to 5.53; NNTH 3).

AUTHORS' CONCLUSIONS

In patients with breast cancer receiving chemotherapy, CSFs have shown evidence of benefit in the prevention of FN. There is evidence, though less reliable, of a decrease of all-cause mortality during chemotherapy and a reduced need for hospital care. No reliable evidence was found for a reduction of infection-related mortality, a higher dose intensity of chemotherapy with CSFs or diminished rates of severe neutropenia and infections. The majority of adverse events reported from CSF use were bone pain and injection-site reactions but no conclusions could be drawn regarding late-term side effects.

[Management of inflammatory breast cancer after neo-adjuvant chemotherapy]

PURPOSE

To assess the benefit of breast surgery for inflammatory breast cancer.

PATIENTS AND METHODS

This retrospective series was based on 232 patients treated for inflammatory breast cancer. All patients received primary chemotherapy followed by either exclusive radiotherapy (118 patients, 51%) or surgery with or without radiotherapy (114 patients, 49%). The median follow-up was 11 years.

RESULTS

The two groups were comparable apart from fewer tumors smaller than 70 mm (43% vs 33%, P=0.003), a higher rate of clinical stage N2 (15% vs 5%, P=0.04) and fewer histopathological grade 3 tumors (46% vs 61%, P<0.05) in the no-surgery group. The addition of surgery was associated with a significant improvement in locoregional disease control (P=0.04) but with no significant difference in overall survival rates or disease-free intervals. Late toxicities were not significantly different between the two treatment groups except for a higher rate of fibrosis in the no-surgery group (P<0.0001), and more lymphedema in the surgery group (P=0.002).

CONCLUSION

Our data suggest an improvement in locoregional control in patients treated by surgery, in conjunction with chemotherapy and radiotherapy, for inflammatory breast cancer.

Use of white blood cell growth factors and risk of acute myeloid leukemia or myelodysplastic syndrome among elderly patients with non-Hodgkin lymphoma

BACKGROUND

The current study was conducted to evaluate the association between colony-stimulating factor (CSF) use and the risk of developing therapy-related myelodysplastic syndromes or acute myeloid leukemia (t-MDS/AML) among a large cohort of elderly patients with non-Hodgkin lymphoma (NHL) who were treated with chemotherapy.

METHODS

A total of 13,203 NHL patients were identified from the Surveillance, Epidemiology, and End Results-Medicare database who were diagnosed from 1992 through 2002. Patients were followed from their initial chemotherapy date until the date they were diagnosed with t-MDS/AML, death, or last follow-up (October 31, 2006), whichever occurred first.

RESULTS

Overall, 40% (n = 5266) of patients received CSF. During the follow-up period (median follow-up, 2.9 years [range, 1-14.7 years]), 272 (5.2%) patients who were treated with CSF developed t-MDS/AML, compared with 230 (2.9%) patients who did not (P < .0001, log-rank test). The 5-year incidence of t-MDS/AML for patients receiving CSF was 14.1 per 1000 person-years compared with 8.3 per 1000 person-years for patients not receiving CSF. In a multivariable Cox regression analysis adjusted for gender, histology, stage, comorbidities, radiotherapy, and chemotherapy agent, CSF use was found to be independently associated with a 53% increased risk of t-MDS/AML (hazard ratio [HR], 1.53; 95% confidence interval [95% CI], 1.26-1.84). The observed association between CSF use and t-MDS/AML persisted across histologic subgroups (ie, diffuse large B-cell lymphoma, follicular lymphoma, and others). Patients who received both CSF and antimetabolite chemotherapy were found to have a 2.5-fold increased risk of t-MDS/AML (HR, 2.49; 95% CI, 1.91-3.26) compared with patients who received neither agent.

CONCLUSIONS

The current study, which to our knowledge is the first large population-based study published to date, demonstrated that the administration of CSF among elderly NHL patients receiving chemotherapy was associated with an increased risk of t-MDS/AML, although the absolute risk was low.

International expert panel on inflammatory breast cancer: consensus statement for standardized diagnosis and treatment

BACKGROUND

Inflammatory breast cancer (IBC) represents the most aggressive presentation of breast cancer. Women diagnosed with IBC typically have a poorer prognosis compared with those diagnosed with non-IBC tumors. Recommendations and guidelines published to date on the diagnosis, management, and follow-up of women with breast cancer have focused primarily on non-IBC tumors. Establishing a minimum standard for clinical diagnosis and treatment of IBC is needed.

METHODS

Recognizing IBC to be a distinct entity, a group of international experts met in December 2008 at the First International Conference on Inflammatory Breast Cancer to develop guidelines for the management of IBC.

RESULTS

The panel of leading IBC experts formed a consensus on the minimum requirements to accurately diagnose IBC, supported by pathological confirmation. In addition, the panel emphasized a multimodality approach of systemic chemotherapy, surgery, and radiation therapy.

CONCLUSIONS

The goal of these guidelines, based on an expert consensus after careful review of published data, is to help the clinical diagnosis of this rare disease and to standardize management of IBC among treating physicians in both the academic and community settings.

Acute myeloid leukemia or myelodysplastic syndrome in randomized controlled clinical trials of cancer chemotherapy with granulocyte colony-stimulating factor: a systematic review

PURPOSE

To evaluate the risk of acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) and overall mortality in patients receiving chemotherapy with or without granulocyte colony-stimulating factor (G-CSF), a systematic review of randomized controlled trials (RCTs) was conducted.

METHODS

Electronic databases searched through October 2008 identified 3,794 articles for initial screening. Eligibility included solid tumor or lymphoma patients randomly assigned to chemotherapy with or without G-CSF support, > or = 2 years of follow-up, and reporting AML/MDS or all second malignancies. Dual blinded data extraction was performed. Relative risk (RR) and absolute risk (AR) estimates +/- 95% CIs were calculated by the Mantel-Haenszel method.

RESULTS

In the 25 eligible RCTs, 6,058 and 6,746 patients were randomly assigned to receive chemotherapy with and without initial G-CSF support, respectively. At mean and median follow-up across studies of 60 and 53 months, respectively, AML/MDS was reported in 22 control patients and 43 G-CSF-treated patients, with an estimated RR of 1.92 (95% CI, 1.19 to 3.07; P = .007) and AR increase of 0.41% (95% CI, 0.10% to 0.72%; P = .009). Deaths were reported in 1,845 patients randomly assigned to G-CSF and in 2,099 controls, for estimates of RR and AR decrease of 0.897 (95% CI, 0.857 to 0.938; P < .001) and 3.40% (95% CI, 2.01% to 4.80%; P < .001), respectively. Greater RR reduction for mortality was seen for both larger studies (P = .05) and greater chemotherapy dose-intensity (P = .012).

CONCLUSION

Delivered chemotherapy dose-intensity and risk of AML/MDS are increased but all-cause mortality is decreased in patients receiving chemotherapy with G-CSF support. Greater reductions in mortality were observed with greater chemotherapy dose-intensity.

Management of inflammatory breast cancer after neoadjuvant chemotherapy

PURPOSE

To assess the benefit of breast surgery for inflammatory breast cancer (IBC).

METHODS AND MATERIALS

This retrospective series was based on 232 patients treated for IBC. All patients received primary chemotherapy followed by either exclusive radiotherapy (118 patients; 51%) or surgery with or without radiotherapy (114 patients; 49%). The median follow-up was 11 years.

RESULTS

The two groups were comparable apart from fewer tumors <70 mm (43% vs. 33%, p = 0.003), a higher rate of clinical stage N2 (15% vs. 5%, p = 0.04), and fewer histopathologic Grade 3 tumors (46% vs. 61%, p <0.05) in the no-surgery group. The addition of surgery was associated with a significant improvement in locoregional disease control (p = 0.04) at 10 years locoregional free interval 78% vs. 59% but with no significant difference in overall survival rates or disease-free intervals. Late toxicities were not significantly different between the two treatment groups except for a higher rate of fibrosis in the no-surgery group (p <0.0001) and more lymphedema in the surgery group (p = 0.002).

CONCLUSION

Our data suggest an improvement in locoregional control in patients treated by surgery, in conjunction with chemotherapy and radiotherapy, for IBC. Efforts must be made to improve overall survival.

Biology and management of inflammatory breast cancer

Inflammatory breast cancer is an aggressive subtype of a locally advanced breast cancer that is thought to account for approximately 1-5% of all newly diagnosed breast cancers diagnosed in the USA. Historically, IBC was considered to be a uniformly fatal disease with less than 5% of patients surviving past 5 years. With the advent of a multidisciplinary approach to management, survival outcomes have improved with 5-year survival rates of over 40% being reported. Research efforts are now focused on trying to better understand the epidemiological and molecular characteristics of this disease to further improve survival. Two genes, Rhoc GTPase and WISP3, have been identified that have been found to be concordantly altered in the majority of inflammatory breast cancer tumors and may serve as potential targets for future therapeutic agents. The purpose of this review is to summarize the latest epidemiological and molecular characteristics of IBC, describe the difficulties encountered in trying to clinically diagnose this entity, highlight the importance of a multidisciplinary approach and present some of the latest data on the management of this disease.

Inflammatory breast cancer: what are the treatment options?

An otherwise healthy, 68-year-old woman presents to her primary-care physician complaining of right breast enlargement, warmth, and progressive pink to dark red skin changes over the past month. She denies fever, pain, or breast discharge. Physical examination reveals erythema of the whole right breast, warmth, swelling, induration, and nipple retraction. Palpable axillary lymphadenopathy is appreciated on the right only. The left breast is uninvolved. The physician is concerned that she may have inflammatory breast cancer.

Survival time of dogs with inflammatory mammary cancer treated with palliative therapy alone or palliative therapy plus chemotherapy

Seven of 30 female dogs diagnosed with inflammatory mammary cancer were given chemotherapy and palliative treatment, and the other 23 received only palliative treatment. The median survival time of the seven dogs given chemotherapy was 57 days, compared with 35 days for the 23 given only palliative treatment.

Dermal lymphatic invasion and inflammatory breast cancer are independent predictors of outcome after postmastectomy radiation

OBJECTIVES

Inflammatory breast cancer (IBC) is a clinical staging based on history and physical findings. Dermal lymphatic invasion (DLI) can occur with or without IBC. We examine how these independently affect outcome in women treated with postmastectomy radiation.

METHODS

Four hundred thirty-two patients treated with postmastectomy radiation for invasive mammary cancer were assessed. Kaplan-Meier methodology was used to calculate rates of locoregional recurrence (LRR), distant metastases (DM) and overall survival (OS). Variables entered into univariate and multivariate analysis included T stage, IBC, DLI, estrogen receptor/progesterone receptor status, HER-2/neu status, N stage, extracapsular node extension (ECE), and use of chemotherapy (CT). Median follow-up is 58 months.

RESULTS

For all 432 patients, the rate of LRR was 3% and DM 28%. Seven percent are alive with disease (AWD) and 26% are dead of disease (DOD). Thirty-one patients had IBC without DLI, 21 had DLI without IBC, and 18 had both IBC and DLI. For DLI 10% developed LRR, 45% DM, 7.5% are AWD and 50% are DOD. Of patients with IBC, 8% developed LRR, 44% DM, 8% are AWD and 48% DOD. DLI was the only significant independent predictor for LRR (HR 4.8, P < 0.05). Predictors of DM and OS were IBC, > or =4 positive nodes, and CT.

CONCLUSIONS

DLI and IBC are independent predictors of poor outcome after postmastectomy radiation. DLI is associated with an increased risk for LRR, and IBC with worse rates of DM and OS. Patients with both features have worse outcome than those with either alone.

The predictive value of PgR and HER-2 for response to primary systemic chemotherapy in inflammatory breast cancer

BACKGROUND

Inflammatory breast cancer (IBC) is the most aggressive form of primary breast cancer. We examined the relationship between clinicopathological factors and clinical response to primary systemic chemotherapy (PSC) and outcome.

METHODS

Twenty-five patients with IBC were examined. Twelve patients received an anthracycline-based regimen, and 13 patients received an anthracycline-and a taxane-containing regimen as PSC. The expression of hormone receptors and human epidermal growth factor receptor-2 (HER-2) was determined by immunohistochemistry.

RESULTS

The overall clinical response rate was 64.0%. Clinical response to PSC was higher in patients with progesterone receptor (PgR)-positive (P = 0.01) and HER-2-negative (P = 0.03) tumors. Patients with fewer than ten involved axillary lymph nodes (P = 0.01 and P = 0.02, respectively) and with a clinical response to PSC (P = 0.02 and P = 0.01, respectively) showed better distant disease-free survival and overall survival.

CONCLUSION

In patients with IBC, PgR-positive and HER-2-negative tumors are more sensitive to anthracycline-based PSC. Patients with extensive residual tumor (ten or more lymph-nodes involved, no response to PSC) after PSC had unfavorable prognoses.

Does chemotherapy-induced neutropaenia result in a postponement of adjuvant or neoadjuvant regimens in breast cancer patients? Results of a retrospective analysis

In 2005, 224 patients received adjuvant/neoadjuvant chemotherapy for breast cancer in a single institution according to daily practices. Regimens consisted of epirubicin-based chemotherapy (FEC100, four or six cycles), or three cycles of FEC100 followed by three cycles of docetaxel. An absolute blood count was carried out every 3 weeks, 1–3 days before planned chemotherapy cycle. Overall, 1238 cycles were delivered. An absolute neutrophil count (ANC) <1.5 × 10⁹ l⁻¹ before planned chemotherapy was found in 171 cycles. Of these, 130 cycles (76%) were delivered as planned regardless of whether ANC levels recovered, and 41 (24%) were delayed. None of these patients developed a febrile neutropaenia. Haematopoietic support (granulocyte colony-stimulating factor (G-CSF)) was required in 12 cycles. We found that the majority of patients with an ANC <1.5 × 10⁹ l⁻¹ before planned chemotherapy received planned doses, without complications and need for G-CSF.