Clinical outcomes of platinum-based chemotherapy in patients with advanced breast cancer: An 11-year single institutional experience

Visceral crisis in metastatic breast cancer: an old concept with new perspectives

Visceral Crisis (VC) in breast cancer is a critical scenario when the burden of metastatic disease results in rapid deterioration of organ functions. There are no widely accepted objective clinical criteria for the definition of VC, and different studies have reported diverse clinical conditions such as visceral crises. Diagnosis of VC is associated with a dismal prognosis and the management of this condition is currently based on limited retrospective evidence and expert opinions. International guidelines have recommended cytotoxic polychemotherapy in the management of VC, to achieve rapid symptomatic control and preserve organ function. Nevertheless, in the case of hormone receptor-positive breast cancer, the role of chemotherapy as the treatment of choice for VC has been recently questioned, since endocrine therapy plus CDK4/6 inhibitors yielded similar response rates, with better quality of life. For HER2-positive and triple-negative breast cancer, combined chemotherapy (plus HER2-directed therapy for HER2-positive) remains a standard option for VC, but novel effective drugs such as antibody-drug conjugates are emerging and their role in the VC context shall soon be elucidated. This review aims to critically discuss the definition, prognosis, management, and future directions regarding the visceral crisis in metastatic breast cancer.

Estrogen receptor positive breast cancer: contemporary nuances to sequencing therapy

The treatment landscape of hormone receptor-positive, human epidermal growth factor receptor 2-negative metastatic breast cancer has evolved dramatically in recent years. While the combination of endocrine therapy and a cyclin-dependent kinase 4/6 inhibitor is accepted as standard first-line treatment in most settings without visceral crisis, newer therapies have challenged traditional treatment models where cytotoxic chemotherapy was previously felt to be the only second-line option at time of progression. The incorporation of next-generation sequencing has led to the identification of molecular targets for therapeutic agents, including phosphatidylinositol 3-kinase and ESR1, though similar pathways can be targeted even in the absence of a mutation, such as with use of inhibitors of mammalian target of rapamycin. Current data also supports the use of cyclin-dependent kinase inhibitors beyond progression, even prior to the patient's first introduction to chemotherapy. The abundance of therapeutic options not only delay time to cytotoxic chemotherapy and antibody-drug conjugate initiation, but has resulted in improvement in breast cancer survivorship. Many unanswered questions remain, however, as to the most efficacious way to sequence these novel agents. To assist in this decision-making, we will review the existing data on systemic therapy and propose a treatment paradigm.

Case series of metastatic breast cancer patients with visceral crisis treated with CDK4/6 inhibitors

There is an ongoing clinical dilemma of how best to treat patients who present themselves with visceral crisis. The time needed to undo the state of visceral crisis is the most relevant outcome for this patient group. We describe four patients treated with CDK4/6 inhibitor plus endocrine therapy for HR+/HER2- metastatic breast cancer who presented themselves with a visceral crisis. Two of them are male and three of them had synchronous metastatic breast cancer. Two patients had lymphangitis carcinomatosis of the lungs, one extensive disease of the eye and one of the liver. Time to first clinical response was observed within a few weeks in three patients. For one patient a switch to chemotherapy was needed. These cases show that treatment with CDK4/6 inhibitors can achieve a rapid response in patients experiencing visceral crisis. We conclude that chemotherapy is not the sole possibility in visceral crisis, and that CDK4/6 inhibitors can be considered as well.

CDK4/6 inhibitors versus weekly paclitaxel for treatment of ER+/HER2- advanced breast cancer with impending or established visceral crisis

PURPOSE

ER+/HER2- advanced breast cancer (ABC) with visceral crisis (VC) or impending VC (IVC) is commonly treated with chemotherapy instead of CDK4/6 inhibitors (CDK4/6i). However, there is little evidence to confirm which treatment is superior. This study compared outcomes of patients with ER+/HER2- ABC and IVC/VC treated with CDK4/6i or weekly paclitaxel.

METHODS

Patients with ER+/HER2- ABC receiving first line treatment at a large tertiary UK cancer centre from 1-Mar-2017 to 30-Jun-2021 were retrospectively identified. Hospital records were screened for IVC/VC affecting the liver, lungs/mediastinum, gastrointestinal tract and/or bone marrow. Baseline demographics, clinical data and survival outcomes were recorded up to 30-Jul-2022.

RESULTS

27/396 (6.8%) patients with ABC who received CDK4/6i and 32/86 (37.2%) who received paclitaxel had IVC/VC. Median time to treatment failure (TTF), progression-free survival (PFS) and overall survival (OS) were significantly longer in the CDK4/6i compared to paclitaxel cohort: TTF 17.3 vs. 3.5 months (HR 0.33, 95%CI 0.17-0.61, p = 0.0002), PFS 17.8 vs. 4.5 months (HR 0.38, 95%CI 0.21-0.67, p = 0.002), OS 24.6 vs. 6.7 months (HR 0.37, 95%CI 0.20-0.68, p = 0.002). The median time to first improvement in IVC/VC was similar in patients receiving CDK4/6i compared to paclitaxel (3.9 vs. 3.6 weeks, p = 0.773). Disease control at 4 months was not significantly different in the CDK4/6i and paclitaxel cohorts (77.8% vs. 59.4%, p = 0.168). In multivariate analysis, treatment with CDK4/6i was independently associated with a longer PFS compared to paclitaxel (HR 0.31, 95%CI 0.12-0.78, p = 0.015).

CONCLUSION

In this retrospective study, patients with ER+/HER2- ABC and IVC/VC treated with CDK4/6i had a significantly better survival compared to those treated with weekly paclitaxel. Further prospective studies that minimise possible selection bias are recommended.

Clinical Review on the Management of Breast Cancer Visceral Crisis

Visceral crisis is a life-threatening clinical condition requiring urgent treatment and accounts for 10-15% of new advanced breast cancer diagnoses, mainly hormone receptor-positive/human epidermal growth factor 2 negative. As its clinical definition is an open topic with nebulous criteria and much room for subjective interpretation, it poses a challenge for daily clinical practice. International guidelines recommend combined chemotherapy as first-line treatment for patients with visceral crisis, but with modest results and a very poor prognosis. Visceral crisis has always been a common exclusion criterion in breast cancer trials, and the available evidence mainly comes from limited retrospective studies which are not sufficient to draw solid conclusions. The outstanding efficacy of innovative drugs, such as CDK4/6 inhibitors, questions the role of chemotherapy in this setting. In the lack of clinical reviews, we aim to critically discuss the management of visceral crisis, advocating future treatment perspectives for this challenging condition.

Different treatment regimens in breast cancer visceral crisis: A retrospective cohort study

Objective

Breast cancer visceral crisis (VC) is caused by excessive tumor burden leading to severe organ dysfunction with poor prognosis. Traditional chemotherapy reduces the quality of life of patients without significantly improving survival. The aim of this study was to investigate the clinical characteristics of patients with VC and the prognosis by using different treatment options.

Methods

According to the 5th European School of Oncology (ESO)–European Society for Medical Oncology (ESMO) international consensus guidelines for advanced breast cancer guidelines (ABC 5), patients who were treated in the First Hospital of Jilin University from 2018 to 2022 and diagnosed with breast cancer VC were retrospectively analyzed. The analysis focused on the characteristics of the patients, the treatment regimens, and prognosis.

Results

A total of 133 patients were included in this study. As for metastasis breast cancer subtype, 92 (69.18%) were hormone receptor (HR) positive, human epidermal growth factor receptor 2 (HER-2) negative, 20 (15.04%) had HER-2 overexpression, and 21 (15.78%) were triple negative. All patients had an mOS of 11.2 months (range, 1.1–107.8 months). In different types of VC, the median overall survival (mOS) of bone marrow metastasis (BMM) was 18.0 months (range, 2.0–107.8 months), that of diffuse liver metastasis (DLM) was 8.1 months (range, 1.3–30.2 months), and that of meningeal metastasis (MM) was 9.0 months (range, 1.2–53.8 months). In 92 HR+, Her-2− patients using different treatment regimens, mOS was 6.2 months (range, 1.2–29.8 months) in the chemotherapy group while it was 24.3 months (range, 3.1–107.8 months) in the endocrine therapy (ET) group. Multivariate Cox regression analysis suggested that Eastern Cooperative Oncology Group (ECOG) scores and type of VC were associated with survival.

Conclusion

Prognosis varied in different types of VC. Patients with BMM had the best prognosis, and DLM had the worst. As treatment options continue to progress, our retrospective study showed a significant prolongation of overall survival (OS) in patients with VC compared to previous studies.

Cisplatin-mediated activation of glucocorticoid receptor induces platinum resistance via MAST1

Agonists of glucocorticoid receptor (GR) are frequently given to cancer patients with platinum-containing chemotherapy to reduce inflammation, but how GR influences tumor growth in response to platinum-based chemotherapy such as cisplatin through inflammation-independent signaling remains largely unclear. Combined genomics and transcription factor profiling reveal that MAST1, a critical platinum resistance factor that reprograms the MAPK pathway, is upregulated upon cisplatin exposure through activated transcription factor GR. Mechanistically, cisplatin binds to C622 in GR and recruits GR to the nucleus for its activation, which induces MAST1 expression and consequently reactivates MEK signaling. GR nuclear translocation and MAST1 upregulation coordinately occur in patient tumors collected after platinum treatment, and align with patient treatment resistance. Co-treatment with dexamethasone and cisplatin restores cisplatin-resistant tumor growth, whereas addition of the MAST1 inhibitor lestaurtinib abrogates tumor growth while preserving the inhibitory effect of dexamethasone on inflammation in vivo. These findings not only provide insights into the underlying mechanism of GR in cisplatin resistance but also offer an effective alternative therapeutic strategy to improve the clinical outcome of patients receiving platinum-based chemotherapy with GR agonists.