Early breast cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up

Immune-induced thrombocytopenia by pembrolizumab: case report and review of literature

Immune-checkpoint blockades (ICBs) are now used in early-stage diseases like triple-negative breast cancer (TNBC). While effective, they can cause severe toxicities. We report the first case of life-threatening immune thrombocytopenia (ITP) induced by pembrolizumab during neoadjuvant chemo-immunotherapy for early TNBC. A 42-year-old woman with early-stage TNBC developed grade 4 thrombocytopenia, diagnosed as ITP, after 107 days of pembrolizumab treatment. She required intensive care unit (ICU) admission and high-dose steroids, and intravenous immunoglobulin therapy, leading to a rapid recovery. ITP is a rare but potentially fatal complication of immunotherapy, with an incidence of less than 1% and a mortality rate of up to 20% in affected patients. Immediate recognition and steroid therapy are critical, as platelet transfusion is usually ineffective. Diagnosis is often delayed due to its similarity to chemotherapy-induced marrow toxicity. Immunotherapy-induced ITP generally contraindicates further use of the treatment. ITP, although uncommon, is a serious complication of immunotherapy requiring immediate intervention. The growing use of immunotherapy necessitates increased awareness of its potential toxicities among healthcare providers.

CircATP5C1 promotes triple-negative breast cancer progression by binding IGF2BP2 to modulate CSF-1 secretion

Triple-negative breast cancer (TNBC) is a common malignant disease among females and severely threatens the health of women worldwide. Nowadays, circular RNAs (circRNAs) aroused our interest for their functions in human cancers, including TNBC. However, the mechanism of most circRNAs in the progression of TNBC remains unclear. We found a novel circRNA named circATP5C1, whose function in TNBC remains uncovered. Tissue microarray was used to analyze the association between the expression of circATP5C1 and the prognoses of TNBC patients. Gain-and loss-of-function experiments were performed to validate the biological functions of circATP5C1 in different TNBC cell lines. RNA-seq analyses were conducted to find out the target genes regulated by circATP5C1. RNA pull-down assay and mass spectrometry were used to select the proteins associated with circATP5C1. RNA FISH-immunofluorescence and RNA immunoprecipitation (RIP) were complemented to validate the interaction between circATP5C1 and its binding protein. CircATP5C1 was identified to have predictive function in prognosis of TNBC patients. CircATP5C1 advanced the progression of TNBC cells. Mechanistically, Colony stimulating factor 1 (CSF-1) is a vital downstream gene regulated by circATP5C1. The alteration of CSF-1 expression level was validated due to the interaction between circATP5C1 and insulin-like growth factor 2 mRNA binding protein 2 (IGF2BP2). Rescue experiments demonstrated that circATP5C1 accelerates the progression of TNBC partly via binding with IGF2BP2 to increase the secretion of CSF-1. This study uncovers a novel mechanism of circATP5C1/IGF2BP2/CSF-1 pathway in regulating progression of TNBC.

How can we optimize the surgical management of the axilla in breast cancer since the MonarchE trial?

PURPOSE

Results of MonarchE trial have changed adjuvant therapy for estrogen-receptor-positive (ER+), HER-2-negative breast cancer. Given the importance of the extent of nodal disease in this study, surgical management of the axilla has resurfaced as a question asked at multidisciplinary boards.

METHODS

Using data from a cohort of Werkoff (JCO, 2009) in which patients underwent both sentinel lymph node(SLN) biopsy and axillary node dissection (ALND), we assessed the proportion of patients in whom the absence of ALND would have led to a lack of awareness of "high-risk" status. We evaluated the contribution of the Katz nomogram (that predict pN2/N3 stage) to guide possible indications for complementary ALND.

RESULTS

Among the 536 patients, 88 were excluded (ER- and/or isolated cells in SLN). Of patients with 1 or 2 SLN + (n = 352), only 7.9% were pN2/N3. When the ratio (number of SLN + /total number of SLN sampled) was less than 1, only 3.9% were pN2/N3. Patients with 1 or 2 SLN + met the ACOSOG Z0011 criteria so none would benefit from an ALND, but 7.9% of patients at high risk will not receive Abemaciclib. If we use the Katz nomogram (threshold ≤ 5%), this rate decrease at 3.3% but 116 patients will have an ALND with no benefit. With a threshold ≤ 20%, 5% patients at high risk will not receive Abemaciclib but 21 patients will have an ALND with no benefit.

CONCLUSION

The indications for adjuvant Abemaciclib should not lead to surgical escalation in the management of the axilla.

Detection of Circulating Tumor DNA Using a Tissue-Free Epigenomic Assay Is a Highly Prognostic Biomarker in Early-Stage Triple-Negative Breast Cancer

PURPOSE

Clinical tools to monitor treatment response and metastatic risk could improve early-stage triple-negative breast cancer (TNBC) care. Although molecular residual disease assays show promise, their use in the neoadjuvant setting requires rapid turnaround times. Tissue-informed approaches may be challenging for patients with limited biopsy samples. The objectives were to determine the surveillance sensitivity for detecting metastatic recurrence and evaluate the ctDNA response to neoadjuvant therapy (NAT) using a tissue-free epigenomic assay.

EXPERIMENTAL DESIGN

Patients with stage II or III TNBC undergoing neoadjuvant docetaxel and carboplatin chemotherapy on a clinical trial (NCT02124902) followed by surgery with or without adjuvant therapy were included in this study. Blood samples were prospectively collected before, during, and after completion of NAT and after surgery at prespecified surveillance time points. Plasma samples were analyzed by Guardant Reveal.

RESULTS

A total of 119 patients with TNBC were included in the analysis. ctDNA was detected in the postsurgical setting in 8.9% (7/79) of patients, with an 83% (5/6) patient-level surveillance sensitivity for metastatic recurrence and 99.5% (197/198) sample-level specificity. Postsurgical ctDNA detection was prognostic for the shorter recurrence-free interval (HR, 37.7; P < 0.0001). ctDNA detection at the post-NAT presurgical time point was also associated with a shorter recurrence-free interval in patients with residual disease at surgery (HR, 28.2; P < 0.0001).

CONCLUSIONS

In patients with early-stage TNBC, a tissue-free, epigenomic assay demonstrated high specificity and sensitivity for metastatic recurrence. ctDNA detection in the neoadjuvant setting indicated poor prognosis, highlighting its potential role across breast cancer care.

Is switching to T-DM1 still justified in HER2-negative residual breast cancer after neoadjuvant systemic therapy?

The standard of care for HER2-positive and hormone receptor-positive breast cancer patients who receive neoadjuvant chemotherapy (NACT) combined with trastuzumab, with or without pertuzumab, is to continue with adjuvant T-DM1 in cases of an incomplete response according to KATHERINE trial results. However, the optimal management for patients with residual disease with loss of HER2 expression is not widely studied. Loss of HER2 expression after NACT with anti HER2 is a rarer event with questionable value both as a predictive prognostic marker.

Oral Anticancer Therapies: Addressing Nonadherence in Patients With Breast Cancer

This review aims to investigate the issue of treatment nonadherence and to present the available strategies to improve adherence to oral treatments in breast cancer. A literature search was conducted to contextualise the issue of nonadherence, investigate the reasons behind nonadherence, and demonstrate strategies to address treatment nonadherence in breast cancer. Findings indicate that adherence rates decrease while discontinuation rates increase with increasing lengths of breast cancer treatment course. Lack of adherence is proven to be detrimental to treatment outcomes. Patients struggle to adhere to treatment due to inadequate relationships with healthcare providers, lack of information, psychological distress, and side effects. Healthcare providers should evaluate patient's experience to provide the necessary support. Following this assessment, healthcare providers may recommend interventions addressing patient knowledge, psychological distress or side effects. Treatment adherence remains an issue for oral therapeutics in breast cancer. After patient assessment, healthcare providers can offer personalised strategies to improve treatment adherence. The most crucial interventions address patient knowledge, psychological distress, and side effects.

Paclitaxel-related type I Kounis Syndrome in a very young patient with HER2-positive breast cancer and the role of genomics to disentangle a complex therapeutic scenario: a case report and narrative review

We present the first documented oncologic case of a type I Kounis syndrome (KS) following paclitaxel administration, in a very young patient with HER2-positive(+) early-stage breast cancer (BC). KS is a relatively rare acute coronary syndrome triggered by anaphylactic or hypersensitivity reactions, of which there is limited awareness among healthcare providers. It is subdivided in four subtypes depending on cardiac artery medical history. While no established management guidelines exist, its treatment requires addressing severe infusion reactions while ensuring proper myocardial perfusion. We hereby illustrate its successful acute management and report on how tumor genomics through the novel HER2DX assay helped re-defining the entire neo/adjuvant oncologic strategy. HER2DX integrates tumor size and nodal involvement with 27 genes' expression data tracking four biological BC-related and immunologic signatures so to estimate a prognostic and a predictive score. This report demonstrates how clinical and genomic data can be effectively integrated to optimize therapeutic decisions in HER2+ BC, offering a model for personalized care also in atypical and complex cases.

Awareness of genomic testing among patients with breast cancer in Europe

PURPOSE

Genomic testing, involving expression profiling of tumour tissue, is a powerful tool for determining appropriate treatments for certain cancer patients. This study aimed to evaluate awareness of genomic testing in breast cancer patients in five European countries.

METHODS

The survey was initiated by Cancer Patients Europe and developed with patient associations, oncologists, and a psycho-oncologist. Participants were recruited via email and social media and completed a 42-question internet survey.

RESULTS

Of 1383 participants in eligible countries completing the survey, 566 women with current or previous HR+/HER2- breast cancer, potentially eligible for genomic testing, were analysed. 245 (43.3 %) were aged 50-59 years and 381 (67.3 %) had received higher education. 238 participants (42.1 %) had heard about genomic testing; 122 (21.6 %) were informed of their eligibility for testing, and 104 (18.4 %) were given reasons for the test. The majority (N = 479; 84.6 %) felt they lacked sufficient information to decide, and only 139 (24.6 %) opted for testing. Overall, 246 (43.5 %) wanted more information on additional testing and 234 (41.3 %) wanted more information on treatment options. The main information sources were medical professionals (N = 363; 64.1 %) and the internet (N = 351; 62.0 %). However, 398 participants (70.3 %) indicated that their healthcare professionals did not advise them on where to find more information.

CONCLUSIONS

This study highlights insufficient awareness of, and access to, genomic testing in breast cancer. Healthcare professionals need to improve communication with patients regarding genomic testing and involve them in shared decision-making. Likewise, patient associations have a role in providing clear information to patients.

Endocrine Therapy Omission in Estrogen Receptor-Low (1%-10%) Early-Stage Breast Cancer

PURPOSE

Adjuvant endocrine therapy (ET) improves overall survival (OS) in estrogen receptor (ER)-positive early-stage breast cancer (BC). However, the benefit of ET for those with ER-low BC (ER 1%-10%) is unclear.

METHODS

Using the National Cancer Database, we studied patients with high-risk stage I to III, ER-low BC (defined as immunohistochemistry 1%-10%) who received (neo)adjuvant chemotherapy and did or did not initiate ET. OS was analyzed with ET initiation as a time-dependent covariate using Cox proportional hazards regression.

RESULTS

Of 10,362 patients with stage I to III ER-low BC, 7,018 received chemotherapy and met inclusion criteria. ET omission was 42% at 12 months and more common in patients with tumors that were progesterone receptor-negative, human epidermal growth factor receptor 2-negative, higher-grade (grade 2/3) and higher Ki-67 (≥20%; all P < .001) and those who received neoadjuvant chemotherapy (NAC; P < .001). With a median follow-up of 3 years, 586 deaths were observed. In a multivariable analysis, ET omission was associated with a higher risk of death (hazard ratio [HR], 1.23 [95% CI, 1.04 to 1.46]; P = .02), with a greater impact in those with higher ER levels: ER 1%-5% (HR, 1.15 [95% CI, 0.91 to 1.45]; P = .24) versus ER 6%-10% (HR, 1.42 [95% CI, 1.00 to 2.02]; P = .048). Among patients treated with NAC (n = 4,377, 62%), ET omission was associated with worse OS in those with residual disease (RD; HR, 1.26 [95% CI, 1.00 to 1.57]; P = .046) but not in those who achieved a pathologic complete response (HR, 1.06 [95% CI, 0.62 to 1.80]; P = .84).

CONCLUSION

In ER-low, early-stage BC, ET omission is associated with significantly worse OS, especially in patients with RD after NAC and those with higher (6%-10%) ER levels. Until prospective data are available, patients with ER-low BC should be counseled regarding the potential benefit of ET.

Radiomic signatures derived from baseline 18F FDG PET/CT imaging can predict tumor-infiltrating lymphocyte values in patients with primary breast cancer

To determine the value of radiomics data extraction from baseline 18F FDG PET/CT in the prediction of tumor-infiltrating lymphocytes (TILs) among patients with primary breast cancer (BC).We retrospectively evaluated 74 patients who underwent baseline 18F FDG PET/CT scans for BC evaluation between October 2020 and April 2022. Radiomics data extraction resulted in a total of 131 radiomic features from primary tumors. TILs status was defined based on histological analyses of surgical specimens and patients were categorized as having low TILs or moderate & high TILs. The relationships between TILs groups and tumor features, patient characteristics and molecular subtypes were examined. Features with a correlation coefficient of less than 0.6 were analyzed by logistic regression to create a predictive model. The diagnostic performance of the model was calculated via receiver operating characteristics (ROC) analysis.Menopausal status, histological grade, nuclear grade, and four radiomics features demonstrated significant differences between the two TILs groups. Multivariable logistic regression revealed that nuclear grade and three radiomics features (Morphological COMShift, GLCM Correlation, and GLSZM Small Zone Emphasis) were independently associated with TIL grouping. The diagnostic performance analysis of the model showed an AUC of 0.864 (95% CI: 0.776-0.953; p < 0.001). The sensitivity, specificity, PPV, NPV and accuracy values of the model were 69.6%, 82.4%, 64%, 85.7% and 78.4%, respectivelyThe pathological TIL scores of BC patients can be predicted by using radiomics feature extraction from baseline 18F FDG PET/CT scans.

Impact of routine FDG-PET/CT on locoregional treatment decisions in breast cancer patients receiving preoperative systemic therapy

PURPOSE

This study evaluates the clinical impact of routine FDG-PET/CT on locoregional treatment in a large cohort of breast cancer patients scheduled for preoperative systemic therapy (PST).

METHODS

Patients scheduled for PST were identified from a retrospective database between 2011 and 2020 at our hospital. All patients underwent staging by FDG-PET/CT prior to PST. The rate of regional upstaging by FDG-PET/CT compared to initial locoregional staging was assessed, as well as its implications on surgical and radiotherapeutic management. Logistic regression analysis was used to evaluate the correlation between clinical characteristics and regional upstaging by FDG-PET/CT.

RESULTS

Among 1228 eligible patients, FDG-PET/CT detected additional regional lymph node involvement in 145 patients (12 %). This resulted in treatment modifications for 140 patients (11 %), including changes to the axillary surgical approach in 27 patients (2 %), and adjustments to the postoperative radiation therapy plans in 115 patients (9 %). The majority of these modifications occurred in patients initially staged as cN1(1-3) (92/140). Clinical T stage was significantly associated with regional upstaging by FDG-PET/CT.

CONCLUSION

FDG-PET/CT staging before PST frequently identifies additional regional lymph node involvement, significantly altering locoregional treatment strategies in the majority.

Role of imaging based response assesment for adapting neoadjuvant systemic therapy for breast cancer: A systematic review

PURPOSE

The objective of this systematic review is to investigate the role of imaging in response monitoring during neoadjuvant systemic therapy (NST) for breast cancer and assess whether treatment modifications based on imaging response are implemented in clinical practice.

METHODS

A systematic review was conducted, analyzing five clinical practice guidelines and 147 clinical trial publications involving NST for breast cancer. The snowballing technique was employed, using a "start set" of clinical guidelines to trace relevant trials. Additionally, a PubMed search was conducted to identify trials published between 2023-2024. The review analyzed the use of imaging modalities, timing, and response criteria, and whether escalation, de-escalation, or change of treatment occurred based on imaging response.

RESULTS

Imaging was utilized in 81 % (119/147) of the trials, with ultrasound, MRI, and mammography being the most frequently employed modalities. Mid-treatment imaging was applied in 56 % (83/147) of the trials. However, only 15 % (22/147) of the trials implemented treatment modifications based on imaging response, highlighting the limited application of imaging response-guided therapy. No standardized imaging protocols or consistent response-guided treatment strategies were identified across the trials or clinical practice guidelines, with considerable variability in imaging methods, timing, and response criteria.

CONCLUSION

This systematic review underscores the critical need for standardized imaging protocols, response assessment criteria and image-guided treatment decisions. It is therefore evident that imaging for response monitoring during treatment should preferably be performed within clinical trials.

Real-world risk of recurrence and treatment outcomes with adjuvant endocrine therapy in patients with stage II-III HR+/HER2- early breast cancer

BACKGROUND

Despite adjuvant endocrine therapy (ET), recurrence is still a concern for patients with HR+/HER2- early breast cancer (EBC). We assessed recurrence risk in real-world patients with stage II/III HR+/HER2- EBC treated with adjuvant ET.

METHODS

A retrospective analysis was conducted using the ConcertAI Patient360 database (January 1995 to April 2021) of patients with stage II/III HR+/HER2- EBC ≥18 years who underwent surgery and received adjuvant ET. Risk of recurrence was assessed using invasive disease-free survival (iDFS) with adapted STEEP criteria. An ET subanalysis evaluated iDFS, distant disease-free survival, and overall survival in patients receiving adjuvant non-steroidal aromatase inhibitors (NSAI) vs tamoxifen.

RESULTS

In the full analysis cohort (N = 3133), the risk of an iDFS event was 26.1 % at 5 years, rising to 45.0 % at 10 years. Among patients with stage II disease, the risk of an iDFS event at 5 and 10 years was 22.7 % and 40.5 %, respectively; stage III 5- and 10-year risk was 40.4 % and 62.9 %. Patients with node-negative disease had 5- and 10-year risks of 22.1 % and 36.9 %, respectively; node-positive 5- and 10-year risk was 28.9 % and 49.4 %. ET subanalysis showed improved iDFS with NSAI ± ovarian function suppression vs tamoxifen ± ovarian function suppression (HR, 0.83; 95 % CI, 0.69-0.98; p = 0.031); this trend was observed regardless of menopausal status.

CONCLUSIONS

This real-world study highlights the considerable risk of recurrence with adjuvant ET in patients with stage II or III HR+/HER2- EBC (including node-negative disease) and confirms the need for improved treatment options.

Is Immediate Breast Reconstruction an Option for Elderly Women? A Comparative Study Between Elderly and Younger Population

OBJECTIVE

To evaluate the incidence of postoperative complications (POC) in elderly patients (EP) compared to younger patients (YP) following immediate breast reconstruction (IBR) after total mastectomy (TM).

METHODS

This retrospective study included patients treated at the Institut Universitaire of Cancer of Toulouse-Oncopole (IUCT-O) between January 2014 and May 2022. The primary outcome was the incidence of POC within 30 days postoperatively. Secondary outcomes included the delay before initiation of adjuvant treatments and re-hospitalization rates.

RESULTS

Elderly patients had a significantly higher rate of POC compared to younger patients, affecting 27.9% of EP and only 14.8% of YP. However, the severity of complications does not differ significantly between YP and EP (69.1% of major POC for YP and 64.7% for EP, P = .6680). Rates of re-hospitalization within 30 days between the 2 groups are similar (67.3% for YP and 61.8% for EP, P = .5962). Most importantly, these complications are not responsible for a delay in initiating adjuvant treatment compared with the younger population. Age ≥ 70 years and obesity (BMI ≥ 30) were identified as independent risk factors for POC.

CONCLUSION

Despite a higher rate of POC, immediate breast reconstruction can be considered for elderly patients, but these patients should be carefully selected and assessed preoperatively to limit the risk of POC.

Clinicopathological and molecular characterization of inflammatory breast cancer, the prospective INFLAME registry study

Inflammatory breast cancer (IBC) is rare, with challenging diagnostics and unfavorable outcomes. Therefore, more molecular insight into IBC is needed. The comprehensive Dutch prospective INFLAME registry related IBC follow-up and treatment to histopathology and molecular analysis. Of consecutive patients, nationwide identified with newly diagnosed IBC, clinicopathological, treatment and outcome data were collected. Histopathology and RNA-sequencing were related to outcome. 125 IBC patients were enrolled. Forty-one (34%) patients had HER2 + , and 31 (25%) had triple-negative IBC. The estimated 3-year OS was 78% in M0 IBC and 29% in M1. PFS was worst in triple-negative IBC (median 7.9 vs 16.3 and 15.8 months in M1 HER2+ and HR + /HER2- IBC). DFS and OS in M0 IBC were better with guideline-concordant trimodal therapy than without (HR 0.15 and 0.15; p = 0.000005 and 0.00038). The unique prospective INFLAME confirms unfavorable IBC characteristics and outcomes. International efforts may support guideline adherence and identify IBC-specific targets.

Retrospective comprehensive analysis of regional lymph node recurrence in breast cancer patients (REASON study)

BACKGROUND

Randomized trials have progressively enabled the de-escalation of axillary surgery in breast cancer (BC) patients, reducing adverse events without compromising survival. Despite a not negligible rate of residual disease in the axilla after sentinel lymph node (SLN) procedure, the risk of regional lymph node recurrence (RLNR) is very low, due probably to multimodal adjuvant treatments. The characteristics of the small number of patients with RLNR remain poorly characterized and warrant further investigation, especially given their poor prognosis and the current context of ongoing studies exploring further de-escalation of axillary surgery.

METHODS

In this retrospective and single institution study, we analyzed thoroughly a cohort of patients who experienced RLNR as first event between 2009 and 2020. MammaPrint and BluePrint analysis (MB) was performed in available primary invasive cancer tissues.

RESULTS

Forty patients, median age of 52, were analyzed. Disease-free interval was 8.7 years. Most of the patients (65%) had no special type BC. Majority (73%) had hormone receptor positive-HER2 negative (HR + /HER2-) BC, 13% triple negative (TNBC), 6% HER2 + , 8% ductal carcinoma in situ and 3% unknown. The median size of the primary tumor was 1.8 cm (range 0.3-7.0) and 57% had no initial LN involvement. Forty five percent had primary SLN procedure and 53% axillary LN dissection (ALND) of the patients received neo-/adjuvant chemotherapy, 63% endocrine therapy and 68% radiotherapy (50% only in breast). Sixty three percent had only RLNR and 38% had concomitant distant metastases. Among irradiated patients, 63% had some relapse in the radiation field. The MB analysis classified 70% of the analyzed cancers as low-risk luminal A (82% in HR + /HER2-), 15% high-risk luminal B, 10% high-risk basal type, and 5% high-risk HER2 type.

CONCLUSION

Our study confirms that patients treated with SLN do not show a higher risk of LRNR compared to ALND. LRNR is often diagnosed incidentally. Younger age, residual disease post-NAC, no regional radiation, stage II, and initial LN involvement were more represented, as well as patients with endocrine sensitive disease classified as low-risk luminal A by MB. Ongoing trials, including SOUND, INSEMA, and BOOG 2013-08, are further exploring axillary surgery de-escalation.

Bulk-lysis protocols as a sensitive method for investigation of circulating CK19 cells in the peripheral blood of patients with breast cancer by flow cytometry

Invasive Breast Carcinoma (IBC) is a heterogeneous group of tumours with varying responses to treatment. Proteins such as Cytokeratin 19 (CK19) play a crucial role in the prognostic evaluation of patients, demonstrating significant roles in breast tumours and metastatic progression, and are described as biomarkers used for the detection of disseminated cells in lymph nodes or distant organs in clinically metastasis-free patients (cM0). Thus, the objective of this study was to establish a methodology for investigating circulating CK19+ breast cancer cells (CTCs) in peripheral blood to detect the risk of metastasis early. The study included a total of 62 patients who were treated at the University Hospital of Santa Catarina. The patients were divided into two groups based on the radiological diagnosis of BI-RADS®. The control group (n = 15) included patients with BI-RADS® 3 and 4a, whose malignancy risk was equal to or less than 10%. The IBC group (n = 46) comprised patients with BI-RADS® 4b, 4c and 5, whose malignancy risk was greater than 10%. The sample preparation was carried out using the bulk-lysis technique to concentrate the peripheral blood sample. For the evaluation of CTCs, the panel was defined using the expression of CD45, a pan-leukocyte antigen not expressed in mammary cells, along with two markers present only in circulating metastatic cells and not in leukocytes, CK19 and Pan-CK. The samples were acquired using a FACSCanto II flow cytometer, equipped with FACSDiva 8.0 software, until tube drying was complete. Data analysis was conducted using Infinicyt 2.0 software. The results obtained in this study show that out of the total cases of IBC analyzed (n = 47), 6.38% (n = 3) presented CTCs detected by flow cytometry, correlating with the presence of metastases identified by imaging methods (cM1), indicating the efficiency of flow cytometry for the research of neoplastic emboli in peripheral blood. Thus, the development and standardization of flow cytometry tests can offer faster, more sensitive, and precise results, complementing the diagnosis and monitoring of IBC patients.

Effect of chemotherapy timing in triple-negative breast cancer: a real-world evidence study

PURPOSE

Triple-negative breast cancer (TNBC) is an aggressive, heterogeneous malignancy with poor prognosis. The optimal timing of chemotherapy-neoadjuvant (NACT) versus adjuvant (ACT)-remains controversial. This study assessed real-world outcomes in non-metastatic TNBC patients according to chemotherapy timing.

METHODS

This retrospective study (2008-2023) evaluated the impact of chemotherapy timing on overall survival (OS) and event-free survival (EFS) in a cohort of 711 patients. Propensity score (PS) matching with preoperative variables was used to adjust for baseline imbalances, and Cox regression models were applied to account for treatment-related variables.

RESULTS

NACT was administered to 525 patients (73.8%), with a 37.3% pathological complete response (pCR) rate. PS matching yielded 177 patient pairs; tumor stage, age and histologic grade remained unbalanced. In the unadjusted analysis, NACT was associated with worse OS (HR 1.56, 95% CI1.08-2.25, p = 0.018). However, multivariate analysis adjusting for unmatched and postoperative variables showed a potential benefit of NACT for OS (HR 0.53, 95% CI 0.07-4.13, p = 0.545) and EFS (HR 0.94, 95% CI 0.21-4.17, p = 0.932). Tumor stage acted as an effect modifier, and stratified analyses revealed that NACT was superior to ACT in patients with advanced-stage disease who achieved pCR (HR 0.22, 95% CI 0.07-0.7, p < 0.010).

CONCLUSIONS

In our TNBC cohort, chemotherapy timing significantly influenced OS and EFS, particularly in relation to initial tumor stage and pCR status. NACT was more beneficial than ACT in patients with advanced disease who achieve pCR, underscoring its role in both prognostic stratification and therapeutic decision-making.

Immunotherapy in primary hormone-receptor positive breast cancer: A systematic review

Hormone-receptor positive (HR+), HER2 negative breast cancer (BC) is considered immunologically silent, thus investigation of immunotherapy in this subtype has evolved slower. This systematic review offers an overview of the clinical trials investigating the safety and efficacy of ICI in primary HR+/HER2- BC. Literature search was conducted up to October 30, 2022 to identify immunotherapy trials with checkpoint inhibitors in non-metastatic HR+/HER2- breast cancer. 39 trials were identified, mainly in early-phase clinical trials. None of the trials investigate ICI monotherapy and only 2 Phase 3 clinical trials are ongoing. Most trials investigate the use of ICI in the neoadjuvant setting in combination with chemotherapy. 18 trials have reported results and 6 of them efficacy results specifically for HR+/HER2- BC. ICI could be a promising therapeutic strategy for HR+/HER2- BC, however clinical benefit is restricted to subgroups of patients, depending on tumor molecular profile.

In silico discovery of multi-target small molecules and efficient siRNA design to overcome drug resistance in breast cancer via local therapy

In this study, we designed an efficient siRNA for PKMYT1 gene knockdown and evaluated the binding affinity of various natural small molecules to key proteins associated with breast cancer through molecular docking and molecular dynamics (MD) simulations. Subsequently, among these molecules, The small molecule, SCHEMBL7562664, was introduced as a "golden ligand" that showed potent multi-target activity as an antagonist for aromatase, estrogen receptor α, HER2, and PARP10, and as an agonist for MT2 and STING. Next, MD simulations of six protein- golden ligand complexes (PDB IDs: 4QXQ, 5GS4, 5JL6, 5LX6, 6ME6, and 7PCD), performed with GROMACS over 100 ns at 298.15 K, provided valuable information about their structural dynamics. Analysis of the radius of gyration (Rg) revealed that, while five complexes (7PCD, 5GS4, 5LX6, 4QXQ, and 5JL6) maintained compact structures (Rg between 1.7 and 2.3 nm), the 6ME6 complex exhibited a more extended and flexible conformation (average Rg ∼3.4 nm). Complementary RMSD analysis confirmed that most complexes rapidly stabilized with minimal deviations (generally <0.3 nm), whereas the 6ME6 complex showed higher variability, reaching up to 0.67 nm. Furthermore, Binding free energy calculations using MM-GBSA and PBSA methods further supported these findings, with energies ranging from -21.45 ± 2.28 kcal/mol (5LX6) to -39.79 ± 1.34 kcal/mol (6ME6), indicating an optimal balance between intrinsic interactions and desolvation costs in the 6ME6 and 5JL6 systems. Based on DFT results, the golden ligand showed higher stability and lower reactivity compared to control ligands such as aromatase, tamoxifen, and dacomitinib, potentially leading to reduced off-target interactions and a more favorable safety profile. The integration of these data underscores the therapeutic potential of SCHEMBL7562664 as a multi-target agent for breast cancer, with promising pharmacokinetic properties that can be optimized for local treatment by incorporation into a 3D scaffold.

Real-world evidence of febrile neutropenia-related hospitalization on patients with perioperative chemotherapy for early breast cancer in Japan

PURPOSE

To clarify particularly how febrile neutropenia-related hospitalization (FNH) affects patients' daily lives, by analyzing real-world data on FNH among patients with early breast cancer (EBC) receiving perioperative chemotherapy in Japan.

METHODS

This retrospective nationwide large-scale database study was conducted using anonymized claims data from 2010 to 2020. The patients with EBC who had available surgical records were included. Men, those aged < 18 years, and those who had not available chemotherapy records were excluded. FNH was defined as hospitalization during perioperative chemotherapy for EBC, with administration of intravenous antibacterial drugs and a diagnosis of FN, sepsis, infection, or fever.

RESULTS

The analysis population included 33,310 EBC patients with a mean age of 56.9 years, who received a total of 267,535 perioperative chemotherapy cycles. FNH occurred in 1,910 patients (5.73%) and 2144 chemotherapy cycles (0.80%). Median duration of FNH was 6.0 days. Fourth-generation cephalosporins were the most used intravenous antibacterial drugs (50.42%). Median duration of intravenous antibacterial drugs administration was 4.0 days. Therapeutic granulocyte-colony stimulating factor (G-CSF) was used in 1285 patients (67.28%). Median cost for FNH was estimated to be 189 thousand yen in 1,474 chemotherapy cycles with FNH, in which patients received intravenous antibacterial drugs administration for 3-8 days.

CONCLUSION

This nationwide real-world data analysis revealed the incidence, duration, treatment patterns, and medical cost of FNH in patients with EBC receiving perioperative chemotherapy in Japan. These findings indicate that FNH imposes a considerable burden on patients' daily lives, including time and financial impacts, contributing to the implementation of appropriate shared decision-making for primary G-CSF prophylaxis.

Impact of margin distance on recurrence and survival following breast-conserving surgery after neoadjuvant systemic therapy

Current evidence does not support the application of "no-ink-on-tumor" negative margins following breast-conserving surgery (BCS) in breast cancer (BC) patients who have received neoadjuvant systemic treatment (NST). We compared loco-regional free survival (LRFS), disease-free survival (DFS), and overall survival (OS) based on different tumor margin distance thresholds in a cohort of 235 BC patients treated with NST and subsequent BCS between 01/2015 and 12/2019. The 5-year LRFS was 81.6% in patients with "no-ink-on-tumour", margins and 71.0% in those with positive margins (p = 0.584). Margins >1 mm were associated with superior outcomes, with a 5-year LRFS of 84.0% compared to 69.3% in patients with margins ≤1 mm (p = 0.005). Additionally, margins >1 mm were significantly correlated with longer DFS (p = 0.028) and OS (p = 0.001). These findings suggest that a surgical margin distance >1 mm provides the best LRFS, DFS, and OS outcomes for this group of BC patients.

Systematic review of clinical practice guidelines for long-term breast cancer survivorship: assessment of quality and evidence-based recommendations

BACKGROUND

Breast cancer is the most common cancer among women, with improved survival rates due to advances in early diagnosis and therapies. However, long-term survivors (≥5 years post-treatment, disease-free) face persistent physical, psychological, and social challenges requiring tailored, evidence-based care. Despite the growing survivor population, no systematic evaluation of Clinical Practice Guidelines (CPGs) for this group has been conducted. This study assesses the quality of CPGs and their evidence-based recommendations.

METHODS

A systematic review was conducted in PubMed, CINAHL, and Cochrane Library (2015-2023), including guidelines from major oncology organisations. The AGREE II instrument evaluated CPG quality across six domains, and recommendations were classified using a Primary Care survivorship framework: prevention, surveillance, care coordination, and long-term effect management.

RESULTS

Ten CPGs met inclusion criteria, with 7 classified as high quality. Most recommendations focused on prevention (adjuvant therapy, alcohol) and surveillance (follow-up, mammography), while gaps remained in lifestyle guidance, psychosocial support, and management of complications (lymphedema, osteoporosis, cognitive dysfunction). Care coordination and psychosocial interventions were inconsistently addressed.

CONCLUSIONS

Current CPGs inadequately cover the complex needs of long-term survivors, particularly in psychosocial care. Evidence-based, patient-centred guidelines are urgently needed to optimise long-term outcomes and quality of life.

Artificial Intelligence as a Potential Tool for Predicting Surgical Margin Status in Early Breast Cancer Using Mammographic Specimen Images

Background/Objectives: Breast cancer is the most common malignancy among women globally, with an increasing incidence, particularly in younger populations. Achieving complete surgical excision is essential to reduce recurrence. Artificial intelligence (AI), including large language models like ChatGPT, has potential for supporting diagnostic tasks, though its role in surgical oncology remains limited. Methods: This retrospective study evaluated ChatGPT's performance (ChatGPT-4, OpenAI, March 2025) in predicting surgical margin status (R0 or R1) based on intraoperative mammograms of lumpectomy specimens. AI-generated responses were compared with histopathological findings. Performance was evaluated using sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), F1 score, and Cohen's kappa coefficient. Results: Out of a total of 100 patients, ChatGPT achieved an accuracy of 84.0% in predicting surgical margin status. Sensitivity for identifying R1 cases (incomplete excision) was 60.0%, while specificity for R0 (complete excision) was 86.7%. The positive predictive value (PPV) was 33.3%, and the negative predictive value (NPV) was 95.1%. The F1 score for R1 classification was 0.43, and Cohen's kappa coefficient was 0.34, indicating moderate agreement with histopathological findings. Conclusions: ChatGPT demonstrated moderate accuracy in confirming complete excision but showed limited reliability in identifying incomplete margins. While promising, these findings emphasize the need for domain-specific training and further validation before such models can be implemented in clinical breast cancer workflows.

Unveiling the paradigm shift: systemic treatment strategies in small, node-negative breast cancer

The implementation of screening mammography has significantly altered the size distribution of breast tumors, with approximately 20% of newly diagnosed breast cancers measuring 10 mm or smaller with node-negative disease (T1aN0 and T1bN0). The management of these early-stage breast cancers remains a subject of debate. Historically, patients with T1aN0 and T1bN0 breast cancer have been excluded from adjuvant chemotherapy trials due to their excellent prognosis, with reported 10-year disease-specific survival rates exceeding 90%. However, the optimal treatment strategy for this subgroup of patients continues to be controversial, as the potential benefits of adjuvant chemotherapy must be carefully weighed against the risks of overtreatment. In this review, we summarize current evidence on outcomes and treatment strategies, highlight gaps in the literature, and provide future perspectives on the management of T1aN0 and T1bN0 breast cancer, according to immunohistochemical subtypes.

European Association of Neuro-Oncology guideline on molecular testing of meningiomas for targeted therapy selection

Meningiomas are the most common primary intracranial tumors of adults. For meningiomas that progress or recur despite surgical resection and radiotherapy, additional treatment options are limited due to a lack of proven efficacy. Meningiomas show recurring molecular aberrations, which may serve as predictive markers for systemic pharmacotherapies with targeted drugs or immunotherapy, radiotherapy, or radioligand therapy. Here, we review the evidence for a predictive role of a wide range of molecular alterations and markers including NF2, AKT1, SMO, SMARCE1, PIK3CA, CDKN2A/B, CDK4/6, TERT, TRAF7, BAP1, KLF4,ARID1/2, SUFU, PD-L1, SSTR2A, PR/ER, mTOR, VEGF(R), PDGFR, as well as homologous recombination deficiency, genomic copy number variations, DNA methylation classes, and combined gene expression profiles. In our assessment based on the established ESMO ESCAT (European Society for Medical Oncology Scale for Clinical Actionability of molecular Targets) evidence-level criteria, no molecular target reached ESCAT I ("ready for clinical use") classification, and only mTOR pathway activation and NF2 alterations reached ESCAT II ("investigational") classification, respectively. Our evaluations may guide targeted therapy selection in clinical practice and clinical trial efforts and highlight areas for which additional research is warranted.

The potential application of stroma modulation in targeting tumor cells: focus on pancreatic cancer and breast cancer models

The tumor microenvironment (TME) plays a crucial role in cancer development and spreading being considered as "the dark side of the tumor". Within this term tumor cells, immune components, supporting cells, extracellular matrix and a myriad of bioactive molecules that synergistically promote tumor development and therapeutic resistance, are included. Recent findings revealed the profound impacts of TME on cancer development, serving as physical support, critical mediator and biodynamic matrix in cancer evolution, immune modulation, and treatment outcomes. TME targeting strategies built on vasculature, immune checkpoints, and immuno-cell therapies, have paved the way for revolutionary clinical interventions. On this basis, the relevance of pre-clinical and clinical investigations has rapidly become fundamental for implementing novel therapeutical strategies breaking cell-cell and cell -mediators' interactions between TME components and tumor cells. This review summarizes the key players in the breast and pancreatic TME, elucidating the intricate interactions among cancer cells and their essential role for cancer progression and therapeutic resistance. Different tumors such breast and pancreatic cancer have both different and similar stroma features, that might affect therapeutic strategies. Therefore, this review aims to comprehensively evaluate recent findings for refining breast and pancreatic cancer therapies and improve patient prognoses by exploiting the TME's complexity in the next future.

Automated field-in-field planning for tangential breast radiation therapy based on digitally reconstructed radiograph

BACKGROUND

The tangential field-in-field (FIF) technique is a widely used method in breast radiation therapy, known for its efficiency and the reduced number of fields required in treatment planning. However, it is labor-intensive, requiring manual shaping of the multileaf collimator (MLC) to minimize hot spots.

PURPOSE

This study aims to develop a novel automated FIF planning approach for tangential breast radiation therapy using Digitally Reconstructed Radiograph (DRR) images.

METHODS

A total of 78 patients were selected to train and test a fluence map prediction model based on U-Net architecture. DRR images were used as input data to predict the fluence maps. The predicted fluence maps for each treatment plan were then converted into MLC positions and exported as Digital Imaging and Communications in Medicine (DICOM) files. These files were used to recalculate the dose distribution and assess dosimetric parameters for both the PTV and OARs.

RESULTS

The mean absolute error (MAE) between the predicted and original fluence map was 0.007 ± 0.002. The result of gamma analysis indicates strong agreement between the predicted and original fluence maps, with gamma passing rate values of 95.47 ± 4.27 for the 3 %/3 mm criteria, 94.65 ± 4.32 for the 3 %/2 mm criteria, and 83.4 ± 12.14 for the 2 %/2 mm criteria. The plan quality, in terms of tumor coverage and doses to organs at risk (OARs), showed no significant differences between the automated FIF and original plans.

CONCLUSION

The automated plans yielded promising results, with plan quality comparable to the original.

Pathological complete response and prognostic predictive factors of neoadjuvant chemoimmunotherapy in early stage triple-negative breast cancer

Background

Neoadjuvant chemoimmunotherapy (nCIT) has shown promise in treating early-stage triple-negative breast cancer (eTNBC), but predictive biomarkers for pathological response and prognosis remain poorly defined.

Objective

This study aimed to explore pathological complete response and prognostic predictive factors in eTNBC patients treated with nCIT.

Materials and methods

We retrospectively analyzed 112 eTNBC patients who underwent surgery after nCIT at Sun Yat-sen University Cancer Center between June 2019 and June 2023. Pathological response was assessed using Miller-Payne grade. Clinicopathological features and hematologic markers were analyzed with univariate and multivariate logistic regression or Cox regression, as well as Kaplan-Meier survival curves. Objective response rate (ORR), pathological complete response (pCR), and disease-free survival (DFS) were evaluated. Nomograms predicting pCR and DFS were constructed based on significant risk factors and the systemic inflammatory response index (SIRI).

Results

Higher baseline lymphocyte counts (P=0.004) were independently associated with a higher pCR rate, while elevated monocyte counts (P=0.006), neutrophil-to-lymphocyte ratio (P=0.005), platelet-to-lymphocyte ratio (p = 0.005), SIRI (P=0.037), systemic immune-inflammation index (P=0.029), and preoperative SIRI (P=0.010) were associated with a lower pCR rate. Higher baseline SIRI (P= 0.009) was correlated with shorter DFS, while higher preoperative lymphocyte counts (P=0.019) predicted longer DFS. Nomograms incorporating SIRI showed high accuracy in predicting pCR and DFS.

Conclusion

Hematologic inflammatory markers, particularly SIRI, are cost-effective and reliable predictors of prognosis and treatment efficacy in eTNBC patients undergoing nCIT, helping clinicians develop personalized treatment strategies.

Clinical trial registration

https://www.medicalresearch.org.cn/, identifier MR-44-24-046099.

The interplay between the immune response and neoadjuvant therapy in breast cancer

Treatment of early breast cancer is currently experiencing a rapid evolution because of important insight into tumor subtypes and continuous development and improvement of novel therapeutics. Historically considered non-immunogenic, breast cancer has seen a paradigm shift with increased understanding of immune microenvironment, which have revealed extensive heterogeneity in tumor-associated inflammation. Notably, the more aggressive breast cancer subtypes, including triple-negative and HER2-positive, have exhibited favorable responses to combined chemo-immunotherapy protocols. Neoadjuvant therapy has emerged as the standard of care for these tumors, with pathological complete response used as a surrogate endpoint for long-term clinical outcomes and coincidently expediting new drug approval. The neoadjuvant setting affords a unique opportunity for in vivo treatment response evaluation and effects on the tumor microenvironment. In this review, the predictive and prognostic value of the tumor immune microenvironment before, during, and after treatment across various therapeutic regimens, tailored to distinct breast cancer subtypes, is carefully examined.

Predictive factors for pCR and relapse following neoadjuvant dual HER2-blockade in HER2+ breast cancer: an international cohort study

PURPOSE

Neoadjuvant systemic therapy with dual HER2-blockade, trastuzumab and pertuzumab, combined with chemotherapy has become a standard approach in patients with HER2-positive (HER2+) breast cancer (BC). However, the variability in treatment outcomes, such as pathological complete response (pCR) or relapse rates, underscores the need to identify predictive factors to optimize therapeutic strategies. This study aims to explore the relationship between clinicopathological factors and both pCR and disease-free survival (DFS) in an international cohort of patients with HER2+ BC, contributing to defining personalized treatment strategies.

METHODS

An international, multicenter, retrospective cohort study was conducted, including 517 patients with HER2+ BC who received neoadjuvant therapy comprising trastuzumab, pertuzumab, and chemotherapy. Data were collected between January 2016 and December 2023. The relationship between clinicopathological factors and treatment outcomes was analyzed using univariate tests, logistic regression for pCR, and Cox proportional hazards regression for DFS. Kaplan-Meier survival curves with log-rank tests and hazard ratios were used to compare DFS across subgroups.

RESULTS

Multivariable analysis revealed that hormonal receptor (HR) expression and nodal status significantly predicted the achievement of pCR in this cohort. Factors such as age, HR status, tumor grade, Ki-67 index, nodal status, and pathological response were associated with relapse risk.

CONCLUSION

Our real-world data demonstrates that a comprehensive approach considering pCR, age, HR status, and nodal involvement is essential for personalized treatment strategies. These factors should be taken into account when deciding whether to escalate or de-escalate treatment, contributing to improved HER2+ BC patient outcomes.

Expanding screening through the use of liquid biopsy for early cancer detection

Perachino et al. discuss screening through the use of liquid biopsy for early cancer detection. They emphasize the need for exceptionally high sensitivity and specificity when implementing such programs in the general population.

Sentinel Lymph Node Biopsy vs. Axillary Lymph Node Dissection for Early-Stage Breast Cancer and Sentinel Lymph Node Metastasis: An Updated Systematic Review and Meta-Analysis With Special Focus on Locoregional Recurrence and Regional Node Irradiation

Background

The management of early breast cancer patients with metastatic sentinel lymph nodes (SLNs) remains a critical decision point in balancing survival outcomes with surgical morbidities. This study addresses whether sentinel lymph node biopsy (SLNB) with or without regional node irradiation (RNI) can offer comparable survival outcomes to axillary lymph node dissection (ALND).

Objectives

To evaluate overall survival (OS), disease-free survival (DFS), locoregional recurrence (LRR), and mortality outcomes of SLNB (with or without RNI) compared with ALND in patients with metastasis-positive SLNs.

Design

We have performed an updated meta-analysis of randomized controlled trials (RCTs) comparing SLNB alone or with RNI vs. ALND for early breast cancer patients with metastatic SLNs.

Data Sources and Methods

Eligibility criteria included RCTs comparing SLNB ± RNI vs ALND for metastasis-positive SLN. PubMed, EMBASE, the Cochrane library, and online registers were searched for articles comparing SLNB alone vs. ALND for metastasis-positive SLN. Articles were evaluated for risk of bias using Cochrane's revised tool (RoB). The main summary measures using the random effects model were hazard ratio and risk ratio.

Results

Seven RCTs were included in the meta-analysis. Overall survival and DFS were superior in the SLNB group compared to the ALND group. Locoregional recurrence and mortality were comparable between both the groups. After stratifying RCTs with regards to adjuvant RNI, these parameters were still comparable to ALND.

Conclusion

This meta-analysis suggests that SLNB, with or without RNI, offers comparable OS and DFS to ALND for early breast cancer patients with metastasis-positive SLNs. However, the inclusion of studies that did not differentiate between micrometastases and macrometastases may introduce bias, particularly when assessing the impact of RNI. The role of RNI remains debated specially in those with macrometastases, and future research should focus on stratified analyses to clarify this. While SLNB represents a viable alternative to ALND, further trials are needed to define the optimal role in subgroups with high-risk tumor biology.

A Mendelian randomization study investigating the causal associations of 35 blood and urinary metabolite biomarkers with breast cancer development

Breast cancer is the most common cancer among women worldwide. The present study utilized a bidirectional Mendelian randomization methodology to explore the causal associations between 35 blood and urinary metabolic markers and distinct subtypes of breast cancer. The MR-PRESSO method was employed to detect and correct for pleiotropic effects, with statistical significance adjusted using the false discovery rate (FDR). The findings revealed significant causal links between certain metabolic markers and specific breast cancer subtypes. Specifically, glucose (OR: -0.187; 95% CI: -0.344 to -0.030) and glycated hemoglobin (HbA1c) (OR: -0.150; 95% CI: -0.2498 to -0.051) were associated with benign breast cancer. In contrast, statin-adjusted apolipoprotein B (OR: 0.493; 95% CI: 0.029 to 0.957) and low-density lipoprotein (LDL) (OR: 0.550; 95% CI: 0.056 to 1.043), urinary sodium (OR: -3.138; 95% CI: -5.710 to -0.565), and triglycerides (OR: 0.606; 95% CI: 0.0824 to 1.129) were correlated with intraductal carcinoma in situ. Apolipoprotein A (OR: 0.178; 95% CI: 0.053 to 0.304) and high-density lipoprotein (HDL) cholesterol (OR: 0.159; 95% CI: 0.045 to 0.273) were linked to intraductal carcinoma in situ of the breast, while total protein (OR: 0.800; 95% CI: 0.181 to 1.409) and albumin (OR: 0.883; 95% CI: 0.255 to 1.512) were associated with lobular carcinoma in situ. In the reverse analysis, benign breast cancer (OR: 0.014; 95% CI: 0.002 to 0.026) exhibited a correlation with urinary creatinine, and intraductal carcinoma in situ (OR: 0.004; 95% CI: 0.001 to 0.007) with insulin-like growth factor 1 (IGF-1). This study identifies key biomarkers for breast cancer susceptibility and resistance, offering a scientific foundation for further research endeavors.

Impact of the ASTRO 2024 Guideline on Partial Breast Irradiation Eligibility in Breast Cancer Patients (KROG 24-01)

PURPOSE

The American Society for Radiation Oncology (ASTRO) has recently published new guidelines for the eligibility for partial breast irradiation (PBI). This study aims to evaluate the eligibility rates of PBI according to the ASTRO 2017 and 2024 guidelines.

METHODS AND MATERIALS

Patients diagnosed with pTis-T2N0 breast cancer in 2019 from 3 tertiary medical centers were accrued. All patients received standard treatment consisting of breast-conserving surgery followed by radiation therapy. Subsequently, patients were classified according to the ASTRO 2017 and 2024 guidelines.

RESULTS

For invasive breast cancer, 785 patients were included, among whom 192 received PBI. Classification according to the ASTRO guidelines showed a substantial increase in the proportion of patients eligible for PBI: 19.2% were classified as "suitable" under the ASTRO 2017 guidelines, while 42.4% were classified as "strongly recommended" under the ASTRO 2024 guidelines. Among 286 patients diagnosed with ductal carcinoma in situ (DCIS), 50 (17.5%) received PBI. The proportion of PBI-eligible patients nearly doubled, from 27.3% under the ASTRO 2017 guidelines to 51.7% under the ASTRO 2024 guidelines. The expanded age criterion from 50 to 40 years and the removal of the clear resection margin requirement were key factors contributing to this substantial increase in both invasive breast cancer and DCIS.

CONCLUSIONS

The eligibility for PBI has dramatically increased for both invasive breast cancer and DCIS under the ASTRO 2024 guidelines. These findings suggest a potential for increased use of PBI, offering individualized and optimized treatment options in early breast cancer.

Real-World Outcomes of Combination Anthracycline and Taxane Adjuvant Therapies in Early Triple-Negative Breast Cancer: A Moroccan Retrospective Analysis

PURPOSE

Neoadjuvant chemoimmunotherapy followed by adjuvant immunotherapy is the gold standard for treating patients with higher risk early triple-negative breast cancer (TNBC); however, in some cases, these patients undergo surgery followed by chemotherapy-based anthracyclines and taxanes without adhering to the guidelines.

METHODS

Patients with previously untreated stage I, II, and III TNBC who received adjuvant therapy with either doxorubicin and cyclophosphamide (AC) + docetaxel (AC-D), AC + weekly paclitaxel (AC-WP), epirubicin and cyclophosphamide (EC) + docetaxel (EC-D), or EC + WP (EC-WP); older than 18 years; and diagnosed between January 1st, 2011, and December 31st, 2022, were eligible for the study. Disease-free survival (DFS) is the primary reported end point. Overall survival (OS) and safety were the secondary end points.

RESULTS

We included 272 female patients. At a prespecified event-driven data cutoff, with a median follow-up of 26.3 months, the 5-year DFS was 49% (95% CI, 38 to 63) in the AC-D group, 45% (95% CI, 29 to 70) in the AC-WP group, 73% (95% CI, 61 to 100) in the EC-D group, and 72% (95% CI, 44 to 100) in the EC-WP group (hazard ratio [HR], 0.2 [95% CI, 0.06 to 0.67]; P = .08). The 7-year OS was 52% (95% CI, 32 to 83) in the AC-D group, 88% (95% CI, 78 to 99) in the AC-WP group, 95% (95% CI, 88 to 100) in the EC-D group, and 83% (95% CI, 58 to 100) in the EC-WP group (HR, 0.19 [95% CI, 0.06 to 0.66]; P = .03). Most of the grade 3-4 adverse events occurred in the AC-D group, primarily neutropenia, nausea-vomiting, and alopecia.

CONCLUSION

EC-D was linked to a slightly longer survival free of invasive, noninvasive, or distant disease and a significantly longer OS with fewer adverse events. Further studies are needed to confirm and establish long-term clinical benefits.

Determining the optimal use of approved drugs in oncology

Optimising the use of approved drugs requires evidence from post-approval trials that investigate variations of their use. Determining optimal drug use goes beyond the dominant, academic effort to conduct trials to identify effective lower doses of new drugs. Other important therapeutic approaches that use either less, similar, or more drug than the standard dose need testing in clinical trials, to get the most out of these drugs. Trial objectives on survival outcomes vary greatly; some aim for superiority, others for equivalent exposure or non-inferiority. This Personal View aims to inform academic trialists in how to conceive and prioritise questions aimed at determining the optimal use of drugs, taking into account the perspectives of patients, clinicians, and trial funders, to maximise the chances of successful delivery and impact for patients globally.

Adjuvant Chemotherapy May be Waived for Breast Cancer Nonresponders to Neoadjuvant Chemotherapy: A Population-Based Large Cohort Study

PURPOSE

This study aimed to evaluate the efficacy of adjuvant chemotherapy (AC) in breast cancer patients who did not respond to neoadjuvant chemotherapy (NAC) following surgery.

METHOD

A retrospective analysis was performed using a large, population-based cohort to identify breast cancer patients who underwent radical surgery following NAC without achieving a response. Kaplan-Meier analysis and Cox regression models were employed to assess clinical outcomes and prognostic factors. Propensity score matching (PSM) was applied to compare outcomes between patients receiving AC vs. those who did not, followed by subgroup analyses.

RESULTS

A total of 1866 patients were included, of whom 1030 received postoperative AC. The median follow-up time was 68.0 months. Patients receiving AC had a median overall survival (OS) of 124.0 months, compared to 93.0 months for those not receiving AC. However, multivariate analysis indicated that receiving postoperative AC was not an independent prognostic factor. Furthermore, PSM analysis indicated no improvement in long-term survival for patients receiving postoperative AC compared to those not receiving it. Subgroup analysis further supported these findings, revealing no significant differences in OS between AC and Non-AC cohorts across various subgroups.

CONCLUSION

These findings suggest that breast cancer patients unresponsive to NAC may derive limited benefit from subsequent AC. Therefore, the decision to administer AC should be carefully considered, and alternative therapeutic strategies should be explored for these patients.

AI in Breast Cancer Imaging: An Update and Future Trends

Breast cancer is one of the most common types of cancer affecting women worldwide. Artificial intelligence (AI) is transforming breast cancer imaging by enhancing diagnostic capabilities across multiple imaging modalities including mammography, digital breast tomosynthesis, ultrasound, magnetic resonance imaging, and nuclear medicines techniques. AI is being applied to diverse tasks such as breast lesion detection and classification, risk stratification, molecular subtyping, gene mutation status prediction, and treatment response assessment, with emerging research demonstrating performance levels comparable to or potentially exceeding those of radiologists. The large foundation models are showing remarkable potential in different breast cancer imaging tasks. Self-supervised learning gives an insight into data inherent correlation, and federated learning is an alternative way to maintain data privacy. While promising results have been obtained so far, data standardization from source, large-scale annotated multimodal datasets, and extensive prospective clinical trials are still needed to fully explore and validate deep learning's clinical utility and address the legal and ethical considerations, which will ultimately determine its widespread adoption in breast cancer care. We hereby provide a review of the most up-to-date knowledge on AI in breast cancer imaging.

Interaction between redox regulation, immune activation, and response to treatment in HER2+ breast cancer

In HER2+ breast cancer (BC), neoadjuvant therapy represents an ideal scenario for translational research, considering pathological complete response (pCR) as an endpoint. In these patients, achieving pCR after neoadjuvant therapy is associated with a better prognosis. However, biomarkers are needed to tailor optimal treatment for each patient. Evaluating tumour-infiltrating lymphocytes (TILs) has gained attention in predicting pCR. In the context of metastatic disease, TILs also appear to play a role in predicting outcomes. The interaction between the presence of TILs and reactive oxygen species (ROS) remains an area to be explored. ROS are critical for tumour cell homeostasis, and different levels can trigger differential biological responses in cancer cells and their microenvironment. Nevertheless, the influence of ROS on treatment efficacy and prognosis in patients with HER2+ BC remains to be elucidated. In this article, we reviewed the interplay between treatment response, immune system activation, and ROS production in HER2+ BC and suggested novel areas of intervention and research. We also present a bioinformatic analysis demonstrating that the altered expression of several redox-related genes could be associated with the prevalence of immune cell populations in the tumour microenvironment and with patient survival. New biomarkers are thus suggested and should be further explored to tailor the best treatment to each patient.

TP53 Mutations and Phosphatidylinositol 3-Kinase/AKT Pathway Alterations Are Key Determinants of Breast Cancer Outcome Independent of Subtype and Stage

PURPOSE

Breast cancer (BC) is a heterogeneous disease with genetic alterations influencing prognosis and treatment response. TP53 mutations (TP53muts) are present in approximately 30% of BC, but their prognostic impact remains controversial. In addition, the phosphatidylinositol 3-kinase (PI3K)/Ak strain transforming (AKT) pathway is frequently altered and represents a promising therapeutic target for BC. Understanding the combined prognostic impact of TP53mut and PI3K/AKT pathway alterations across BC subtypes remains underexplored.

METHODS

This retrospective cohort study integrated clinical and genomic data from 4,265 patients with BC from the Molecular Taxonomy of Breast Cancer International Consortium (n = 2,509) and the Memorial Sloan Kettering Cancer Center (n = 1,756). Genetic profiling identified TP53mut and PI3K/AKT pathway alterations (AKT1, AKT2, AKT3, PIK3CA, PTEN, RICTOR). Survival outcomes were assessed using Kaplan-Meier survival analysis and multivariable Cox proportional hazards models.

RESULTS

In 3,807 patients with available gene alteration status, TP53mut was associated with younger age, higher tumor grade, advanced stage, and aggressive subtypes (P < .001). TP53mut was associated with worse survival independent of subtype, stage, age, and grade (hazard ratio [HR], 1.43 [95% CI, 1.24 to 1.66]; P < .0001). The type of TP53mut has also been found to be prognostic in BC. PI3K/AKT pathway alterations were more frequent in TP53mut tumors and independently associated with worse survival (HR, 1.18 [95% CI, 1.03 to 1.35]; P = .0173). The combined presence of TP53mut and PI3K/AKT alterations resulted in the worst survival outcomes (HR, 1.61 [95% CI, 1.32 to 1.97]; P < .0001).

CONCLUSION

TP53mut status is a critical prognostic factor in BC, independent of subtypes and stage, and its adverse impact is amplified by PI3K/AKT pathway alterations. These findings emphasize the integration of genetic profiling into routine clinical practice to refine treatment strategies and identify potential therapeutic targets for this high-risk population.

The role of BRCA1/2 genetic testing in perioperative breast cancer management: advancing shared decision-making and personalized care

BACKGROUND

BRCA1/2 genetic testing has become essential in breast cancer management, guiding surgical decisions, surveillance, and targeted therapies. While it has revolutionized personalized medicine, challenges remain in its implementation.

OBJECTIVE

This review summarizes the impacts of BRCA1/2 genetic testing on surgical choices and risk-reducing strategies, plus its role in the therapy of PARP inhibitors.

METHODS

We analyzed recent studies, clinical guidelines, and meta-analyses focusing on the clinical utility of BRCA1/2 genetic testing in breast cancer management.

RESULTS

Breast-conserving therapy (BCT) does not conclusively impact survival in BRCA1/2 mutation carriers, making it a viable option for those preferring breast conservation. The benefit of contralateral risk-reducing mastectomy remains uncertain, but it may be considered if the patient understands the risks and benefits. Risk-reducing salpingo-oophorectomy effectively prevents ovarian and fallopian tube cancers and improves survival. MRI is superior to mammography for early cancer detection in high-risk women and is beneficial for surveillance when contralateral mastectomy is not performed. BRCA1/2 testing is also essential for determining eligibility for PARP inhibitor therapy, particularly olaparib, which has shown efficacy in early breast cancer patients with BRCA1/2 mutations in the OlympiA trial.

CONCLUSION

BRCA1/2 genetic testing enhances personalized breast cancer treatment but presents challenges in patient selection, decision-making, genetic counseling, and insurance coverage. A multidisciplinary approach is essential for shared decision-making and improved outcomes in BRCA1/2 mutation carriers.

[Molecular imaging and radioligand in breast cancer]

Molecular imaging plays a crucial role in the diagnosis, staging, and monitoring of breast cancer. The most commonly used tracer at present is 18F-FDG, a marker of cellular metabolism, making 18F-FDG PET/CT a major imaging modality in the management of breast neoplasms. However, this tracer has limitations, particularly for low-grade ductal or lobular neoplasms, which exhibit low avidity for 18F-FDG. The 68Ga-FAPI tracer, which targets activated fibroblasts and whose uptake is independent of tumor aggressiveness, is currently under investigation and could serve as an excellent alternative to 18F-FDG in certain cases. Additionally, new tracers targeting novel biological pathways of the tumor, including hormonal receptors or HER2, are being developed. These tracers enable whole-body assessment of specific biomarker expressions on cancer cells, offering a more precise understanding of the disease. This approach could help tailor treatments to the molecular characteristics of each tumor, enabling personalized strategies that improve therapeutic efficacy and patient quality of life. Finally, inspired by the model of 177Lu-PSMA used in prostate cancer, researchers are exploring the potential to couple these tracers with therapeutic agents to develop targeted radionuclide therapy for breast neoplasms.

High-LET Proton Irradiation Significantly Alters the Clonogenic and Tumorigenic Potential of Human Breast Cancer Cell Lines In Vitro and In Vivo

BACKGROUND

The implementation of proton beam irradiation (PBI) for breast cancer (BC) treatment is rapidly advancing due to its enhanced target coverage and reduced toxicities to organs at risk. However, the effects of PBI can vary depending on the cell type. This study aimed to explore the effects of PBI on two BC cell lines, MCF7 and MDA-MB-231.

METHODS

The relative biological effectiveness (RBE) of PBI was assessed using a clonogenic assay. DNA double-strand break (DSB) repair, epithelial-mesenchymal transition (EMT), and filamentous actin (F-actin) were evaluated using immunofluorescence analysis. The extent of entosis and the senescence-associated β-galactosidase (SA-β-gal) activity were estimated by cytochemistry analysis. The influence of the extracellular matrix was evaluated by cultivating cells in both adherent two-dimensional (2D) environments and within 3D fibrin gels of varying stiffness. The metastatic propensity of cells was investigated using migration tests and the cell encapsulation of carboxylate-modified fluorescent nanoparticles. The comparative tumorigenic potential of cells was investigated using an in vivo model of the chick embryo chorioallantoic membrane (CAM).

RESULTS

PBI demonstrated superior efficacy in eliminating MCF7 and MDA-MB-231 cells with RBE 1.7 and 1.75, respectively. Following PBI, MDA-MB-231 cells exhibited significantly lower clonogenic survival compared to MCF7, which was accompanied by the accumulation of phosphorylated histone H2AX (γH2AX), p53-binding protein 1 (53BP1) and Rad51 foci of DNA DSBs repair proteins. After surviving 7 days post-PBI, MCF7 cells exhibited 2.5-fold higher levels of the senescence phenotype and entosis compared to the MDA-MB-231 offspring. Both PBI-survived cell lines had greater capability for 2D collective migration, but their metastatic potential was significantly reduced. A significant influence of extracellular matrix stiffness on the correlation between F-actin expression in PBI-survived cells-an indicator of cell stiffness-and their ability to uptake nanoparticles, a trait associated with metastatic potential, was observed. PBI-survived MDA-MB-231RP subline exhibited a hybrid EMT phenotype and a 70% reduction in tumor growth in the in vivo model of the chick embryo CAM. In contrast, PBI-survived MCF7RP cells exhibit mesenchymal-to-epithelial transition (MET)-like features, and their in vivo tumor growth increased by 66% compared to parental cells.

CONCLUSIONS

PBI triggers various cellular responses in different BC cell lines, influencing tumor growth through mechanisms like DNA damage repair, stress-induced premature senescence (SIPS), and alterations in the stiffness of tumor cell membranes. Our insights into entosis and the effect of extracellular matrix stiffness on metastatic propensity (nanoparticle uptake) enhance the understanding of the role of PBI in BC cells, emphasizing the need for more research to optimize its therapeutic application.

Extended adjuvant endocrine therapy in early breast cancer: finding the individual balance

Endocrine therapy (ET) is a cornerstone in the management of patients with hormone receptor-positive early breast cancer, which accounts for over 70% of cases worldwide. The efficacy of adjuvant ET for 5 years in reducing the risk of recurrence and improving survival outcomes is well documented. However, the risk for late relapses, occurring >5 years after initial treatment, has prompted exploration of longer treatment durations. Extending ET beyond the traditional 5-year period offers additional benefit in reducing the risk of recurrence and improving long-term outcomes. Nevertheless, determining the optimal duration and identifying suitable candidates for extended therapy is often nuanced. This review aims to comprehensively evaluate the current landscape of extended ET in breast cancer management. It provides an overview of the rationale behind extending endocrine treatment in both premenopausal and postmenopausal women, with a focus on clinical trials and observational studies supporting extended therapy. Furthermore, it emphasizes the significance of considering associated toxicities in patient management. It also explores novel strategies involving the combination of ET with new drugs, leading to an evolution of treatment paradigms that may make the need for extended therapy obsolete.

Exosomal circRNAs: key modulators in breast cancer progression

Breast cancer (BC) poses significant challenges globally, necessitating a deeper understanding of its complexities. Exosomes are cell-specific secreted extracellular vesicles of interest, characterized by a lipid bilayer structure. Exosomes can carry a variety of bioactive components, including nucleic acids, lipids, amino acids, and small molecules, to mediate intercellular signaling. CircRNAs are a novel class of single-stranded RNA molecules, characterized by a closed-loop structure. CircRNAs mainly exert ceRNA functions to intricately modulate gene expression and signaling pathways in breast cancer, influencing tumor progression and therapeutic responses. The unique packaging of circRNAs within exosomes serves as novel genetic information transmitters, facilitating communication between BC cells and microenvironmental cells, thereby regulating critical aspects of BC progression, immune evasion, and drug resistance. Besides, exosomal circRNAs possess the capabilities of serving as diagnostic and therapeutic biomarkers of BC, due to their stability, specificity, and regulatory roles in tumorigenesis and metastasis. Therefore, this review aims to elucidate the novel roles and mechanisms of exosomal circRNAs in BC progression, as well as their potential for diagnosis and therapeutics. The ongoing investigations of exosomal circRNAs will potentially revolutionize treatment paradigms and improve patient outcomes of BC.

Chemotherapy receipt in affected BRCA1/2 and PALB2 carriers with operable breast cancer: the impact of early detection and pre-diagnostic awareness on clinical outcomes and treatment

PURPOSE

While enhanced breast screening of germline pathogenic variant (GPV) carriers results in earlier stage at diagnosis, the impact of tumour biology and GPV on chemotherapy receipt in early-stage disease remains understudied.

METHODS

We retrospectively reviewed treatment administered following a first diagnosis of BRCA1/2- and PALB2-associated breast cancer between 2002 and 2022. Chemotherapy receipt was compared according to tumor size, biologic subtype, and GPV. Subgroup analyses were performed in women with T1N0 disease and in those with pre-diagnostic awareness of their GPV.

RESULTS

Overall, 309 affected BRCA1/2 and PALB2 carriers with a median age of 43 years at breast cancer diagnosis (range, 19-80 years) were included; 160 (51.8%) BRCA1, 130 (42.1%) BRCA2, and 19 (6.1%) PALB2 carriers. Chemotherapy was administered in 70.9% of index breast cancer cases and was significantly associated with younger age, tumor size, histologic grade, nodal status, and biologic subtype (all p < 0.05). Chemotherapy receipt was 80.6% in BRCA1-associated breast cancers compared to 56.9% in BRCA2 and 84.2% in PALB2 associated breast cancers (p < 0.001). In subgroup analysis of early stage, T1N0 disease, chemotherapy was administered in 78.9% BRCA1 and 59.5% BRCA2/PALB2 patients (p = 0.04). Pre-diagnostic awareness of a GPV in BRCA1/2 or PALB2 was associated with smaller invasive tumors (%T1, 50% vs. 32.9%; p = 0.002) and node-negative invasive disease (87.1% vs. 72.2%), as well as a reduced likelihood of chemotherapy (59.7% vs. 74.3%, p = 0.02).

CONCLUSION

Chemotherapy receipt is high in BRCA1/2 and PALB2-associated breast cancers including in early stage, node-negative disease. Pre-diagnostic awareness is associated with a lower likelihood of requiring chemotherapy for a breast cancer diagnosis.

Therapy of early breast cancer: current status and perspectives

Medical advancements in breast cancer are truly remarkable. Especially in recent years, numerous new therapeutics have been approved and surgical strategies have been de-escalated for specific patient groups. In the therapeutic setting, CDK4/6 inhibitors as oral maintenance therapy in early breast cancer and immune checkpoint inhibitors (Pembrolizumab) for triple-negative breast cancer (BC) are noteworthy. In the surgical field, prospective randomized controlled trials have currently explored the possibility to deescalate axillary surgery by omitting sentinel lymph node excision (INSEMA, SOUND). As a result, there have been significant improvements in prognosis and a reduction in surgical morbidity for patients. Many exciting trials are underway, and it remains to be seen whether antibody-drug conjugates beyond trastuzumab emtansine, will find their way into the treatment lines for early-stage BC. Furthermore, the integration of artificial intelligence in both diagnostics and treatment recommendation evaluation is a promising area with great potential.