Impact of neoadjuvant chemotherapy and pathological complete response on eligibility for breast-conserving surgery in patients with early breast cancer: A meta-analysis

Long-term overall survival of patients who undergo breast-conserving therapy or mastectomy for early operable HER2-Positive breast cancer after preoperative systemic therapy: an observational cohort study

Background

Understanding the survival outcomes associated with breast-conserving therapy (BCT) and mastectomy after preoperative systemic therapy (PST) enables clinicians to provide more personalized treatment recommendations. However, lack of firm survival benefit data limits the breast surgery choices of human epidermal growth factor receptor 2 (HER2)-positive breast cancer patients who receive PST. We sought to determine whether BCT or mastectomy after PST for early operable HER2-positive breast cancer is associated with better long-term survival outcomes and determine the degree to which PST response affects this association.

Methods

In this observational cohort study, we compared the long-term survival outcomes of BCT and mastectomy after PST for HER2-positive breast cancer and evaluated the impact of PST response on the relationship between breast surgery performed and survival outcomes. Our cohort included 625 patients with early operable HER2-positive breast cancer who received PST followed by BCT or mastectomy between January 1998 and October 2009. These patients also received standard postoperative radiation, trastuzumab, and endocrine therapy as indicated clinically. We used propensity score matching to assemble mastectomy and BCT cohorts with similar baseline characteristics and used Kaplan-Meier plots and Cox proportional hazards regression to detect associations between surgery types and outcomes. Furthermore, in this study, we analyzed the original data of 625 patients using the inverse probability of treatment weighting (IPTW) method to enhance the reliability of the comparison between the mastectomy and BCT cohorts by addressing potential confounding variables.

Findings

Propensity score matching yielded cohorts of 221 patients who received BCT and 221 patients who underwent mastectomy. At the median follow-up time of 9.9 years, compared with BCT, mastectomy was associated with worse overall survival (hazard ratio, 1.66; 95% confidence interval [CI]: 1.08-2.57; P = 0.02). In patients who had axillary lymph node pathological complete response, mastectomy was associated with worse overall survival before matching (hazard ratio, 2.17; 95% CI: 1.22-3.86; P < 0.01) and after matching (hazard ratio, 2.12; 95% CI: 1.15-3.89; P = 0.02). Among patients with pathological complete response in the breast, the survival results did not differ significantly between BCT and mastectomy patients. IPTW method validated that BCT offers better overall survival in patients who had axillary lymph node pathological complete response.

Interpretation

People with HER2-positive breast cancer who have already had PST are more likely to survive after BCT, especially if they get a pathological complete response in the axillary lymph nodes. These findings underscore the necessity for further investigation into how responses to PST can inform the choice of surgical intervention and the potential impact on overall survival. Such insights could lead to the development of innovative tools that support personalized surgical strategies in the management of breast cancer.

Funding

This work was supported by grants from the Nantong Science and Technology Project (JCZ2022079), Nantong Health Commission Project (QA2021031, MSZ2023040) and National Natural Science Foundation of China (No. 82394430).

Neoadjuvant chemotherapy for stage II-III breast cancer: a single-center experience

INTRODUCTION

We conducted this study to reflect a single-center experience with the use of neoadjuvant systemic chemotherapy (NAC) for the management of women with operable breast cancer.

METHODS

We conducted a retrospective chart review on all women presenting with operable, stage II-III, breast cancer and were scheduled for NAC at Suez Canal University Hospital. The primary outcome of this study was to estimate the proportion of patients with breast cancer who become eligible for breast-conserving surgery (BCS) after (NAC).

RESULTS

A total of 147 patients were included. Before the initiation of chemotherapy, only 66 (44.9%) patients were indicated for (BCS). A total of 40 (49.4%) new patients, out of the 81 patients who were ineligible before chemotherapy, became eligible for BCS after NAC (95% CI 39.3-61.9%). On the other hand, 8 (12.1%) patients became ineligible for BCS after NAC, out of 66 patients who were initially eligible. Out of the 98 eligible patients for BCS after chemotherapy, 72 (73.5%) patients underwent the surgery, and the remaining 26 (26.5%) patients chose modified radical mastectomy (MRM). A total of 55 out of 72 (76.4%) patients achieved pathological complete response (pCR). One woman (0.1%) experienced relapse in the 3rd year of follow-up and three women (2%) experienced relapse in the 5th year of follow-up. We found a statistically significant relationship between patients who became eligible for breast-conserving surgery and both age and estrogen receptor negativity (p = 0.001 and 0.007, respectively).

CONCLUSION

NAC can play a crucial role in increasing the rate of eligibility for BCS among women with operable, stage II-III, breast cancer.

A prospective cohort study identifying radiologic and tumor related factors of importance for breast conserving surgery after neoadjuvant chemotherapy

INTRODUCTION

Neoadjuvant chemotherapy (NAC) is an established treatment option for early breast cancer, potentially downstaging the tumor and increasing the eligibility for breast-conserving surgery (BCS). The primary aim of this study was to assess the rate of BCS after NAC, and the secondary aim was to identify predictors of application of BCS after NAC.

MATERIALS AND METHODS

This was an observational prospective cohort study of 226 patients in the SCAN-B (Clinical Trials NCT02306096) neoadjuvant cohort during 2014-2019. Eligibility for BCS was assessed at baseline and after NAC. Uni- and multivariable logistic regression analyses were performed using covariates with clinical relevance and/or those associated with outcome (BCS versus mastectomy), including tumor subtype, by gene expression analysis.

RESULTS

The overall BCS rate was 52%, and this rate increased during the study period (from 37% to 52%). Pathological complete response was achieved in 69 patients (30%). Predictors for BCS were smaller tumor size on mammography, visibility on ultrasound, histological subtype other than lobular, benign axillary status, and a diagnosis of triple-negative or HER2-positive subtype, with a similar trend for gene expression subtypes. Mammographic density was negatively related to BCS in a dose-response pattern. In the multivariable logistic regression model, tumor stage at diagnosis and mammographic density showed the strongest association with BCS.

CONCLUSION

The rate of BCS after NAC increased during the study period to 52%. With modern treatment options for NAC the potential for tumor response and BCS eligibility might further increase.

A generalized non-linear model predicting efficacy of neoadjuvant therapy in HER2+ breast cancer

Neoadjuvant therapy (NAT) is currently recommended to patients with human epidermal growth factor receptor 2-positive breast cancer (HER2+ BC) that typically exhibit a poor prognosis. The tumor immune microenvironment profoundly affects the efficacy of NAT. However, the correlation between tumor-infiltrating lymphocytes or their specific subpopulations and the response to NAT in HER2+ BC remains largely unknown. In our study, the immune infiltration status of 295 patients was classified as "immune-rich" or "immune-poor" phenotypes. The "immune-rich" phenotype was significantly positively related to pathological complete response (pCR). Ten genes were correlated with both pCR and the immune phenotype based on the results of spline and logistic regression. We constructed a generalized non-linear model combining linear and non-linear gene effects and successfully validated its predictive power using an internal and external validation set (AUC = 0.819, 0.797; respectively) and a clinical set (accuracy = 0.75).

Predictors of success in establishing orthotopic patient-derived xenograft models of triple negative breast cancer

Patient-derived xenograft (PDX) models of breast cancer are an effective discovery platform and tool for preclinical pharmacologic testing and biomarker identification. We established orthotopic PDX models of triple negative breast cancer (TNBC) from the primary breast tumors of patients prior to and following neoadjuvant chemotherapy (NACT) while they were enrolled in the ARTEMIS trial (NCT02276443). Serial biopsies were obtained from patients prior to treatment (pre-NACT), from poorly responsive disease after four cycles of Adriamycin and cyclophosphamide (AC, mid-NACT), and in cases of AC-resistance, after a 3-month course of different experimental therapies and/or additional chemotherapy (post-NACT). Our study cohort includes a total of 269 fine needle aspirates (FNAs) from 217 women, generating a total of 62 PDX models (overall success-rate = 23%). Success of PDX engraftment was generally higher from those cancers that proved to be treatment-resistant, whether poorly responsive to AC as determined by ultrasound measurements mid-NACT (p = 0.063), RCB II/III status after NACT (p = 0.046), or metastatic relapse within 2 years of surgery (p = 0.008). TNBC molecular subtype determined from gene expression microarrays of pre-NACT tumors revealed no significant association with PDX engraftment rate (p = 0.877). Finally, we developed a statistical model predictive of PDX engraftment using percent Ki67 positive cells in the patient's diagnostic biopsy, positive lymph node status at diagnosis, and low volumetric reduction of the patient's tumor following AC treatment. This novel bank of 62 PDX models of TNBC provides a valuable resource for biomarker discovery and preclinical therapeutic trials aimed at improving neoadjuvant response rates for patients with TNBC.

Neoadjuvant Chemotherapy for Stage II–III Breast Cancer: A Single-center Experience.. [DOI: 10.21203/rs.3.rs-968632/v3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Introduction We conducted this study to reflect a single-center experience with the use of neoadjuvant systemic chemotherapy for the management of women with operable breast cancer. Methods We conducted a retrospective chart review on all women presenting with operable, stage II-III, breast cancer and were scheduled for neoadjuvant systemic chemotherapy at Suez Canal University Hospital. The primary outcome of this study was to estimate the proportion of patients with operable breast cancer who become eligible for breast conservative surgery (CBS) after neoadjuvant systemic chemotherapy. Results A total of 147 patients were included. Before the initiation of chemotherapy, only 66 (44.9%) patients were indicated for breast conservative surgery (CBS). A total of 40 (50.6%) new patients, out of the 81 patients who were ineligible before chemotherapy, became eligible for breast conservative surgery after neoadjuvant chemotherapy (95% CI 39.3–61.9%). On the other hand, eight (12.1%) patients became ineligible for breast conservative surgery after neoadjuvant chemotherapy. Out of the 98 eligible patients for breast conservative surgery after chemotherapy, 72 (73.5%) patients underwent the surgery, and the remaining 26 patients chose total modified radical mastectomy (MRM). A total of 55 (76.4%) patients achieved pathological complete response (pCR). One woman (0.1%) experienced relapse at the 3rd year of follow-up and three women (2%) experienced relapse at the 5th year of follow-up. The difference between patients who underwent breast conservative surgery and total mastectomy was not statistically significant (p = 0.22 and 0.07, respectively). Conclusion Neoadjuvant chemotherapy can play a crucial role in increasing the rate of eligibility for breast conservative surgery among women with operable, stage II-III, breast cancer.

Breast surgery after neoadjuvant therapy

PURPOSE OF REVIEW

The standard of care in breast surgery has changed, from mastectomy to breast conserving surgery whenever possible, and from axillary dissection to sentinel node biopsy. Neoadjuvant systemic approaches have broadened the indications for organ-conserving and less mutilating surgery, but also raise important questions of balancing locoregional treatment de-escalation and protecting excellent long-term outcomes.

RECENT FINDINGS

Recent studies have aimed at investigating the safety of de-escalating surgical approaches not only in the upfront breast surgery situation but also after neoadjuvant systemic therapy. This pertains to both the safety of breast conserving surgery - including more complex oncoplastic approaches - within the new (posttherapeutic) anatomical extent of the residual disease, but more controversially to de-escalating surgical treatment of the axilla. While sentinel node biopsy appears to be the standard of care for node-negative disease also after primary systemic therapy, the optimal procedure in situations of posttherapeutic node-positive disease remains highly controversial.

SUMMARY

Both breast and axillary surgery after neoadjuvant systemic therapy for women with breast cancer has undergone multiple paradigm changes in recent years. For the primary tumor in the breast, breast-conserving surgery constitutes the standard of care, and unnecessary mastectomies should be strongly discouraged. For axillary surgery, sentinel-node biopsy should be aimed at, and completion axillary dissections minimized for situations of extensive disease and or poor neoadjuvant treatment response. Additional techniques such as targeted axillary dissection are currently under evaluation in clinical trials.

Changes in kinetic heterogeneity of breast cancer via computer-aided diagnosis on MRI predict the pathological response to neoadjuvant systemic therapy

OBJECTIVE

To evaluate whether the computer-aided diagnosis (CAD)-extracted kinetic heterogeneity of breast cancer on MRI and changes therein during treatment were associated with the pathological response to neoadjuvant systemic therapy (NST).

MATERIALS AND METHODS

Consecutive patients with invasive breast cancer, who underwent NST followed by surgery between 2014 and 2020, were retrospectively evaluated. Using a commercial CAD system, kinetic features (angiovolume, peak enhancement, delayed enhancement profiles, and kinetic heterogeneity) of breast cancer were assessed with pre- and mid-treatment MRI. Multivariate logistic regression was used to identify the associations between CAD-extracted kinetic features and pathological complete response (pCR).

RESULTS

A total of 130 patients (mean age, 55 years) were included, 37 (28.5%) of whom achieved a pCR. When the pre- and mid-treatment MRI data were compared, the pCR group exhibited greater changes in kinetic heterogeneity (86.14 ± 32.05% vs. 8.50 ± 141.01%, p < 0.001) and angiovolume (95.20 ± 14.29% vs. 19.89 ± 320.16%; p < 0.001) than the non-pCR group. Multivariate regression analysis showed that a large change in kinetic heterogeneity (odds ratio (OR) = 1.030, p < 0.001), age (OR = 0.931, p = 0.005), progesterone receptor negativity (OR = 7.831, p = 0.001), and HER2 positivity (OR = 3.455, p = 0.017) were associated with pCR.

CONCLUSIONS

A greater change in the CAD-extracted kinetic heterogeneity of breast cancer between pre- and mid-treatment MRI was associated with a pCR in patients on NST.

KEY POINTS

A greater change in kinetic heterogeneity was associated with a pathological complete response. Computer-aided diagnosis-extracted kinetic heterogeneity might serve as a quantitative biomarker of therapeutic efficacy.

Neoadjuvant approach in patients with early breast cancer: patient assessment, staging, and planning

Neoadjuvant treatment (NAT) has become an option in early stage (stage I-II) breast cancer (EBC). New advances in systemic and targeted therapies have increased rates of pathologic complete response increasing the number of patients undergoing NAT. Clear benefits of NAT are downstaging the tumor and the axillary nodes to de-escalate surgery and to evaluate response to treatment. Selection of patients for NAT in EBC rely in several factors that are related to patient characteristics (i.e, age and comorbidities), to tumor histology, to stage at diagnosis and to the potential changes in surgical or adjuvant treatments when NAT is administered.

Imaging and histologic confirmation is performed to assess extent of disease y to confirm diagnosis. Besides mammogram and ultrasound, functional breast imaging MRI has been incorporated to better predict treatment response and residual disease. Contrast enhanced mammogram (CEM), shear wave elastography (SWE), or Dynamic Optical Breast Imaging (DOBI) are emerging techniques under investigation for assessment of response to neoadjuvant therapy as well as for predicting response. Surgical plan should be delineated after NAT taking into account baseline characteristics, tumor response and patient desire.

In the COVID era, we have witnessed also the increasing use of NAT in patients who may be directed to surgery, unable to have it performed as surgery has been reserved for emergency cases only.

Invited commentary on "Neoadjuvant pertuzumab plus trastuzumab in combination with anthracycline-free chemotherapy regimen in patients with HER2 positive breast cancer: Real-world data from a single center in India"

The article "Neoadjuvant pertuzumab plus trastuzumab in combination with anthracycline-free chemotherapy regimen in patients with HER2 positive breast cancer: Real-world data from a single center in India" have presented the experience of neoadjuvant DCPH in Indian population. Though being a small retrospective study, results from this study have provided the medical community a real-world data on Asian (in particular Indian) population. In Hong Kong, we have reviewed our prospective database. 264 primary breast cancer patients underwent neoadjuvant chemotherapy followed by definitive breast surgery in my institution from 2005 to 2015. Mean age was 48.9 years old. Mean tumor size was 44.9 mm. 58 (22%) patients had HER2 positive invasive cancer. 16 (6.1%) were stage 1, 213 (80.7%%) were stage 2, the rest were stage 3 cancers. PCR rate was observed in 29 (11%) patients after neoadjuvant chemotherapy. Amongst which, PCR rate is higher in HER2 positive breast cancers (25.9%) followed by triple negative cancers (13.3%) and then luminal cancers (5.7%). Patients with HER2 positive cancers had 70.7% reduction of breast tumor volume on sonographic measurement after anti-HER2 neoadjuvant treatment. Breast cancers with HER2 positive cancers were associated with higher PCR rate (p= 0.029). Overall rate of breast conserving surgery (BCS) increased to from 14.7% to 30.5% after neoadjuvant treatment. Neoadjuvant systemic treatment results in significant tumor shrinkage in many patients. It has expanded the indication of BCS, although BCS rate in Asia remains relatively low due to personal choice and small breast volume in the population.

Factors affecting pathological complete response after neoadjuvant chemotherapy in breast cancer: a single-center experience

OBJECTIVE

The aim of this study was to examine the characteristics of patients admitted to our hospital with a diagnosis of breast cancer who reached pathological complete response after being operated following eight cycles of neoadjuvant chemotherapy.

METHODS

Between 2015-2020, patients with pathological complete response who were operated on after neoadjuvant chemotherapy and sent to our clinic for radiotherapy were evaluated.

RESULTS

The median age of the patients was 51 years. The most common histological type was invasive ductal cancer. The number of pathological complete response patients was 74 (28%), and the number of non-pathological complete response patients was 188 (72%). Patients with pathological complete response had a smaller tumor diameter than the non-pathological complete response group (p=0.001). For pathological complete response, T1 stage, N1 stage, NG 3, Ki-67 >20%, negative estrogen receptor, negative progesterone receptor, positive Cerb-B2, and adding trastuzumab to chemotherapy were statistically significant (p<0.05). Before neoadjuvant chemotherapy, stage T1-T2 (p=0.036), LN0-1 (p=0.026), Cerb-B2 positivity (p=0.025), and an initial nuclear grade of three (p=0.001) were found to be the factors affecting pathological complete response.

CONCLUSIONS

With neoadjuvant chemotherapy, the size of locally advanced tumors decreases, allowing breast conserving surgery. The neoadjuvant chemotherapy response can be used as an early indicator of the prognosis of patients with breast cancer. Today, neoadjuvant chemotherapy is also used for patients with early-stage, operable breast cancer because it has been shown in many studies that reaching pathological complete response is associated with positive long-term results. If we can identify patients who have reached pathological complete response before neoadjuvant chemotherapy, we think we can also determine a patient-specific treatment plan at the beginning of treatment.

Radiomics of MRI for the Prediction of the Pathological Response to Neoadjuvant Chemotherapy in Breast Cancer Patients: A Single Referral Centre Analysis

Simple Summary

Nowadays, the only widely recognized method for evaluating the efficacy of neoadjuvant chemotherapy is the assessment of the pathological response through surgery. However, delivering chemotherapy to not-responders could expose them to unnecessary drug toxicity with delayed access to other potentially effective therapies. Radiomics could be useful in the early detection of resistance to chemotherapy, which is crucial for switching treatment strategy. We determined whether tumor radiomic features extracted from a highly homogeneous database of breast MRI can improve the prediction of response to chemotherapy in patients with breast cancer, in addiction to biological characteristics, potentially avoiding unnecessary treatment.

Abstract

Objectives: We aimed to determine whether radiomic features extracted from a highly homogeneous database of breast MRI could non-invasively predict pathological complete responses (pCR) to neoadjuvant chemotherapy (NACT) in patients with breast cancer. Methods: One hundred patients with breast cancer receiving NACT in a single center (01/2017–06/2019) and undergoing breast MRI were retrospectively evaluated. For each patient, radiomic features were extracted within the biopsy-proven tumor on T1-weighted (T1-w) contrast-enhanced MRI performed before NACT. The pCR to NACT was determined based on the final surgical specimen. The association of clinical/biological and radiomic features with response to NACT was evaluated by univariate and multivariable analysis by using random forest and logistic regression. The performances of all models were assessed using the areas under the receiver operating characteristic curves (AUC) with 95% confidence intervals (CI). Results: Eighty-three patients (mean (SD) age, 47.26 (8.6) years) were included. Patients with HER2+, basal-like molecular subtypes and Ki67 ≥ 20% presented a pCR to NACT more frequently; the clinical/biological model’s AUC (95% CI) was 0.81 (0.71–0.90). Using 136 representative radiomics features selected through cluster analysis from the 1037 extracted features, a radiomic score was calculated to predict the response to NACT, with AUC (95% CI): 0.64 (0.51–0.75). After combining the clinical/biological and radiomics models, the AUC (95% CI) was 0.83 (0.73–0.92). Conclusions: MRI-based radiomic features slightly improved the pre-treatment prediction of pCR to NACT, in addiction to biological characteristics. If confirmed on larger cohorts, it could be helpful to identify such patients, to avoid unnecessary treatment.

Evolving Trends in Surgical Management of Breast Cancer: An Analysis of 30 Years of Practice Changing Papers

The management of breast cancer has evolved into a multidisciplinary evidence-based surgical speciality, with emphasis on conservative surgery. A number of landmark trials have established lumpectomy followed by radiation as the standard of care for many patients. The aim of this study is to construct a narrative review of recent developments in the surgical management of breast cancer and how such developments have impacted surgical practice. A comprehensive literature search of Pubmed was conducted. The latest search was performed on October 31^st, 2020. Search terms “breast cancer” were used in combinations with specific key words and Boolean operators relating to surgical management. The reference lists of retrieved articles were comprehensively screened for additional eligible publications. Articles were selected and reviewed based on relevance. We selected publications in the past 10 years but did not exclude commonly referenced and highly regarded previous publications. Review articles and book chapters were also cited to provide reference on details not discussed in the academic literature. This article reviews the current evidence in surgical management of early-stage breast cancer, discusses recent trends in surgical practice for therapeutic and prophylactic procedures and provides commentary on implications and factors associated with these trends.

Avoiding breast cancer surgery in a select cohort of complete responders to neoadjuvant chemotherapy: The long-term outcomes

BACKGROUND

Lately, there has been a resurgence of interest in de-escalation of breast surgery in complete responders to neoadjuvant chemotherapy (NAC). Advanced cytotoxic & targeted therapies have improved tumour response.This study evaluates long-term outcomes of post-NAC breast cancer patients, in relation to their surgical management dictated by the NAC response.

MATERIALS AND METHODS

Post-NAC breast cancer patients from January 2000 to December 2010 were divided into "No surgery", "WLE" and "Mastectomy" groups. ANOVA and Kaplan-Meier statistical analyses were used to compare overall survival (OS) and disease-free-survival (DFS) in these groups.

RESULTS

This retrospective study included 121 patients with a long median follow-up of 11.5 years. At 10 years the OS was 66.10% and DFS was 59.82%. Complete NAC-responders did not undergo breast surgery but received radiotherapy. Patients were divided into No surgery (n = 28), WLE (n = 44), Mastectomy (n = 49) groups.Comparisons of OS and DFS between groups showed statistically significant differences (p = 0.0003, p = 0.0007 respectively). The no surgery group showed low local recurrence (7.14%).

CONCLUSION

The observed slightly better long-term outcomes with low local recurrences in complete NAC-responders who did not undergo breast surgery but received radiotherapy could be linked to cautious response assessment and meticulous patient selection with early, biologically favourable breast cancer.Importance of PCR assessment cannot be underestimated if breast surgery were to be de-escalated or even omitted in complete NAC-responders.Considering the study limitations, avoiding surgery in all complete NAC-responders may still not be the preferred option. Future appropriate clinical trials with well-defined protocols may pave the way forward.

Mutant Allele Frequency-Based Intra-Tumoral Genetic Heterogeneity Related to the Tumor Shrinkage Mode After Neoadjuvant Chemotherapy in Breast Cancer Patients

The shrinkage mode of tumor extent after neoadjuvant chemotherapy (NAC) is an important index to evaluate the odds of breast-conserving surgery. However, there is no sufficient measurement to predict the shrinkage mode after NAC. In this study, we analyzed 24 patients' formalin-fixed, paraffin-embedded samples before and after treatment and analyzed 456 cancer-related genes panel by using target next-generation sequencing. Meanwhile, the pathological shrinkage mode was reconstructed in three dimensions after surgery, and the genetic heterogeneity level was estimated by mutant-allele tumor heterogeneity (MATH). We measured the genetic intra-tumor heterogeneity and explored its correlation with the shrinkage mode after NAC. A total of 17 matched pair samples of primary tumor tissue and residual tumor tissue were successfully accessed. It was found that the most common mutated genes were TP53 and PIK3CA in both samples before and after NAC, and no recurrent mutations were significantly associated with the shrinkage mode. Besides, the MATH value of formalin-fixed, paraffin-embedded samples before and after NAC was analyzed by the area under the curve of the receiver operating characteristic, and it is feasible to classify patients into concentric shrinkage mode and non-concentric shrinkage mode in NAC based on the MATH threshold of 58. Our findings indicate that the MATH value was associated with the shrinkage mode of breast cancer in a non-linear model. Patients with the MATH value below the threshold of 58 before and after NAC displayed a concentric shrinkage mode. The area under the curve was 0.89, with a sensitivity of 0.69 and specificity of 1. Our study might provide a promising application of intra-tumor heterogeneity that is measured by MATH to make a choice of surgery.

Breast conservation and axillary management after primary systemic therapy in patients with early-stage breast cancer: the Lucerne toolbox

Primary systemic therapy is increasingly used in the treatment of patients with early-stage breast cancer, but few guidelines specifically address optimal locoregional therapies. Therefore, we established an international consortium to discuss clinical evidence and to provide expert advice on technical management of patients with early-stage breast cancer. The steering committee prepared six working packages to address all major clinical questions from diagnosis to surgery. During a consensus meeting that included members from European scientific oncology societies, clinical trial groups, and patient advocates, statements were discussed and voted on. A consensus was reached in 42% of statements, a majority in 38%, and no decision in 21%. Based on these findings, the panel developed clinical guidance recommendations and a toolbox to overcome many clinical and technical requirements associated with the diagnosis, response assessment, surgical planning, and surgery of patients with early-stage breast cancer. This guidance could convince clinicians and patients of the major clinical advancements purported by primary systemic therapy, the use of less extensive and more targeted surgery to improve the lives of patients with breast cancer.

Local Treatment of Triple-Negative Breast Cancer

ABSTRACT

Triple-negative breast cancer, compared with other molecular subtypes, poses particular challenges for optimizing the timing and the extent of locoregional treatments. In the past, the combination of increased rates of both locoregional and distant recurrences led to a preference of radical surgery and extensive radiation therapy; however, since the introduction of more effective chemotherapy, a sharp de-escalation in the extent of locoregional treatments followed. Current evidence confirms that less aggressive surgery in combination with tailored radiation therapy offers improved oncological outcomes combined with better quality of life. However, further research is required to optimize locoregional treatments, considering the significant heterogeneity in biological behavior and tumor response to systemic treatments.

Survival Outcomes for Patients With Clinical Complete Response After Neoadjuvant Chemotherapy: Is Omitting Surgery an Option?

BACKGROUND

Surgery after neoadjuvant chemotherapy (NCT) is an accepted treatment approach for locally advanced and some early-stage breast cancers, even for patients with a clinical complete response (cCR) after NCT. This study sought to evaluate the survival outcomes for patients with cCR to NCT who did not undergo surgery.

METHODS

The National Cancer Data Base (NCDB) was used to identify 93,417 women age 18 years or older with a diagnosis of invasive breast cancer who received NCT between 2010 and 2015. The study identified 350 women with cT1-4, N0-3, and M0 tumors who underwent NCT and did not have surgery. A matched surgical cohort was extracted from the NCDB, and overall survival (OS) was compared between the surgical and nonsurgical patients after NCT.

RESULTS

Of the 350 NCT patients who did not undergo surgery, 45 (12.9%) had cCR, 51 (14.6%) had a partial response, 241 (68.9%) had a response but whether complete or partial was not recorded, and 13 (3.7%) had no response/progression. The 5-year OS was better in the cCR group than in the no-cCR group (96.8% vs 69.8%; p = 0.004). A 5-year OS analysis of the cCR patients without surgery (n = 45; median follow-up period, 37 months) compared with the patients with a pathologic complete response who underwent surgery (n = 3938; median follow-up period, 43 months) showed no statistically significant difference (96.8% vs 92.5%, respectively; p = 0.15).

CONCLUSION

This retrospective cohort study demonstrated that active surveillance or de-escalation therapy may be an option for patients who achieve cCR. Prospective studies are underway to determine whether a subgroup of patients may forgo surgery in the setting of cCR after NCT.

Ovarian stimulation for oocyte vitrification does not modify disease-free survival and overall survival rates in patients with early breast cancer

RESEARCH QUESTION

Does ovarian stimulation for oocyte vitrification affect disease-free survival and overall survival rates in women with early breast cancer?

DESIGN

This cohort study included 259 patients with early breast cancer; 148 patients underwent ovarian stimulation, whereas 111 patients did not. Patients were treated between January 2008 and December 2016. To calculate the disease-free survival time and overall survival rate, the time of definitive surgery was defined as the starting point. The follow-up was conducted up to 5 years.

RESULTS

Exposed and non-exposed groups were comparable in tumour, node and metastases classification, Nottingham grade, hormonal receptor status, tumour molecular phenotype, histology and pathology stage. The exposed group was younger than the non-exposed. Recurrences occurred in 9/148 women (6.1%) in the exposed group and 15/111 women (13.5%) in the non-exposed group, with no significant difference. The mean disease-free survival time was 63.9 months (95% confidence interval [CI]: 61.5-66.4) in the exposed group and 60.6 months (95% CI: 56.9-64.2) in the non-exposed, with no significant difference (log-rank [Mantel-Cox] test). Overall survival rates were comparable; 2/148 (1.4%) and 4/111 (3.6%) patients died, in exposed and non-exposed groups, respectively, during the period analysed. Mean overall survival times were 67.2 months (95% CI: 66.2-68.2) in the exposed group and 65.9 months (95% CI: 64.0-67.9) in the unexposed, with no significant difference (log-rank [Mantel-Cox] test).

CONCLUSIONS

This study suggests that ovarian stimulation in patients with early-stage breast cancer is safe in the long term.

Primary medical therapy and breast conservation treatment: the medical oncology perspective

Primary systemic therapy (PST) is a widely adopted strategy for increasing operability and breast conservation rates. Although first generation PST trials failed to demonstrate improvements in disease free and overall survival compared to adjuvant systemic therapy (AST), they did demonstrate a strong association between attainment of pathologic complete response (pCR) and improved survival outcomes, leading to the widespread adoption of pCR as the primary endpoint in subsequent PST trials. First generation trials also showed that preoperative PST can improve breast conservation rates and downstage the axilla. Although individual trials did not demonstrate statistically significant increase in local recurrence with PST when compared to AST, a recent meta-analysis did note an increased in such risk, mainly driven by trials in which surgery was omitted in patients with good response to PST. Successive generations of PST clinical trials have since explored the activity of taxanes, optimization of anthracycline and taxane dose and schedules, incorporation of single and dual anti-HER2 therapy in HER2 overexpressing breast cancer, the use of platinums in triple negative breast cancer, and the role of endocrine therapy in hormone receptor positive breast cancer. While these PST trials have generally found increased pCR rates with the introduction of modern chemotherapy regimens and targeted therapies, they have not consistently demonstrated further improvements in breast conservation rates compared to first generation regimens. The reasons for this are complex and may lie beyond differences in anti-tumour activity between different systemic regimens but rather in other potential confounding factors such as tumour to breast volume ratio, tumour location, multicentricity as well as patient or surgeon preference.

Epithelial-Mesenchymal Transition Markers in Breast Cancer and Pathological Responseafter Neoadjuvant Chemotherapy

The association between pathologic complete response (pCR) following to neoadjuvant chemotherapy (NAC) and the improved survival in breast cancer has been previously reported. The aim of this study was is to explore the expression of several biomarkers described during epithelial-mesenchymal transition (EMT) and the achievement of pCR in different molecular subtypes of breast cancer. We identified archived pathology tissue from patients with breast cancer who received NAC during the year 2014. We performed immunohistochemical analysis of vimentin, nuclear factor κB (NF-κB), epidermal growth factor receptor (EGFR), E-cadherin, estrogen receptor (ER), progesterone receptor, and Her2neu and studied the association between the expression of these markers and pCR. A Fisher exact test for categorical cofactors, an unpaired t test and a nonparametric Wilcoxon test for continuous cofactors were used. The results showed a significant expression of vimentin in triple-negative breast cancer (TNBC; P = .023). An inverse correlation between vimentin and the ER expression (P = .032) was observed. No significant association was noted for vimentin, NF-κB, EGFR, and E-cadherin was associated with pCR. This study suggests that the evaluated EMT related biomarkers are not associated with pCR after NAC chemotherapy in an unselected breast cancer population. Vimentin and NF-κB expressions were associated with TNBC and could be further explored as potential therapeutic targets in this subgroup. A prevalence of vimentin and NF-κB among Hispanic patients with breast cancer warrants further investigation as a possibly contributing to the prevalence of TNBC and adverse prognosis in this population.