Effect of preoperative rescue concomitant FUN/XUN-based chemo-radiotherapy for neoadjuvant chemotherapy-refractory breast cancer

New Strategies for Locally Advanced Breast Cancer: A Review of Inflammatory Breast Cancer and Nonresponders

This review explores the new strategies around the management of locally advanced breast cancer (LABC), particularly for nonresponsive tumors and/or initially unresectable tumors at diagnosis, inclusive of inflammatory breast cancer. Nonresponders to neoadjuvant systemic therapy present a unique clinical challenge. Emerging medical therapeutics as well as considerations for use of radiotherapy and/or surgery in this setting are discussed. Specifically, the use of neoadjuvant radiotherapy for LABC and lymphedema prevention with lymphatic reconstruction following axillary lymph node dissection are reviewed.

Effect of Neoadjuvant Concurrent Chemoradiation on Operability and Survival in Locally Advanced Inoperable Breast Cancer

PURPOSE

Inoperable locally advanced breast cancers (LABCs) are treated with neoadjuvant chemotherapy. We studied the use of neoadjuvant concurrent chemoradiation (NACCRT) in patients with inoperable LABC.

METHODS AND MATERIALS

From May 2017 to December 2021, the study recruited patients with stage III inoperable LABC. Treatment included 4 cycles of doxorubicin and cyclophosphamide and 4 cycles of paclitaxel, along with concurrent radiation therapy to a total dose of 46 Gy. Thereafter, all patients were evaluated for surgery, and additional treatments were given based on receptor status. The effects of NACCRT on pathologic complete response (pCR), operability, and survival were analyzed.

RESULTS

The study involved 202 female patients with a median age of 52 years. Of these, 23.7% had IIIA, 65.3% had IIIB, and 10.8% had IIIC disease. Hormone receptor-positive disease was observed in 44.6% of patients, triple-negative breast cancer was observed in 24.8% of patients, and Human epidermal growth factor receptor 2 (HER2)-positive disease was observed in 30.7% of patients. Modified radical mastectomy (MRM) was performed in 88.1% of patients, 8.5% of patients remained inoperable, and 3.4% of patients declined surgery. Among the patients who underwent MRM, 36.5% of patients had a pCR. Patients who were operable and underwent MRM had complete resections and had negative margins. pCR was observed in 16% with hormone receptor-positive disease, in 45.6% with triple-negative breast cancer, and in 60.7% with HER2-positive disease. Grade 3 skin reactions were observed in 19.3% of patients. Postoperative wound morbidity requiring hospitalization was observed in 10.6% of patients. After a median follow-up of 42 months, the 4-year event-free survival and overall survival rates were 63.4% and 71.5%, respectively. HER2-positive patients who achieved a pCR had significantly improved event-free survival and overall survival.

CONCLUSIONS

Our study shows that using NACCRT can improve operability and survival outcomes in patients with inoperable LABC.

Preoperative Radiation Therapy for Chemorefractory Localized Inflammatory Breast Cancer

PURPOSE

Inflammatory breast cancer (IBC) is a rare breast cancer subtype. Chemorefractory nonmetastatic IBC, defined by locoregional progression under neoadjuvant chemotherapy, is a rare situation with few therapeutic options. Owing to the rarity of this clinical presentation and the lack of specific data, no specific management guidelines exist. We evaluated whether preoperative radiation therapy/chemoradiotherapy could achieve locoregional control after first-line neoadjuvant chemotherapy in patients with IBC.

METHODS AND MATERIALS

Patients with chemorefractory disease receiving preoperative radiation therapy were identified from a retrospective multicenter cohort of consecutive patients with IBC diagnosed between 2010 and 2017 at 7 oncology centers in France.

RESULTS

Overall, 18 patients among the 364 patients (5%) treated for IBC had progressive disease during neoadjuvant chemotherapy. These patients had aggressive tumors with lymph node involvement at diagnosis (n = 17; 94.4%), triple-negative subtype (n = 11; 61.1%), Scarff Bloom and Richardson grade 3 (n = 10; 55.6%), and high Ki67 (median, 56.0%). After preoperative radiation therapy, all patients had a complete (n = 1; 5.6%) or partial (n = 17; 94.4%) locoregional response. One patient (5.6%) experienced acute grade 3 dermatitis. Twelve (66.7%) patients underwent surgery as planned. The estimated median follow-up was 31 months. The median overall survival, disease-free survival, distant metastases-free survival, and locoregional recurrence-free survival were 19 months, 4.5 months, 5 months, and 6 months, respectively. Ultimate locoregional control was obtained for 11 patients (61.1%), and 13 patients (72.2%) experienced metastatic progression. Triple-negative subtype (hazard ratio [HR], 15.54; P = .011) and surgery (HR, 0.23; P = .030) were significantly associated with overall survival in the univariate analysis. In multivariate analyses, the triple-negative subtype remained a significant prognostic factor (HR, 13.04; P = .021) for overall survival.

CONCLUSIONS

Preoperative radiation therapy is a feasible approach with acceptable toxicities. It allowed surgery and ultimate locoregional control in a majority of patients. The lack of translation into better survival has been a challenge, in part owing to the metastatic propensity of patients with chemorefractory IBC, especially in the overrepresented triple-negative population in this series.

Radiation for inflammatory breast cancer: Updates

Inflammatory breast cancer (IBC) is a diagnosis based on a constellation of clinical features of edema (peau d'orange) of a third or more of the skin of the breast with a palpable border and a rapid onset of breast erythema. Incidence of IBC has increased over time, although it still makes up only 1-4% of all breast cancer diagnoses. Despite recent encouraging data on clinical outcomes, the published local-regional control rates remain consistently lower than the rates for non-IBC. In this review, we focus on radiotherapy, provide a framework for multi-disciplinary care for IBC, describe local-regional treatment techniques for IBC; highlight new directions in the management of patients with metastatic IBC and offer an introduction to future directions regarding the optimal treatment and management of IBC.

[Radiotherapy and targeted therapy for the management of breast cancer: A review]

The purpose of this study was to review the current knowledge regarding combinations of the most commonly used targeted therapies or those under development for the management of breast cancer with radiation therapy. Several studies have shown that the combination of radiation therapy and tamoxifen increased the risk of radiation-induced lung toxicity; therefore, the two modalities are generally not given concurrently. The combination of HER2 inhibitors (trastuzumab, pertuzumab) and radiation therapy appeared to be safe. However, trastuzumab emtansine (T-DM1) should not be given concomitantly with brain radiation therapy because this combination may increase the risk of brain radionecrosis. The combination of radiation therapy with other new targeted therapies such as new selective estrogen receptor modulators (SERDs), lapatinib, cell cycle inhibitors, immune checkpoint inhibitors, or molecules acting on DNA damage repair seems feasible but has been mainly evaluated on retrospective or prospective studies with small numbers of patients. Moreover, there is a great heterogeneity between these studies regarding the dose and fractionation used in radiotherapy, the dosage of systemic treatments and the sequence of treatments used. Therefore, the combination of these new molecules with radiotherapy should be proposed sparingly, under close monitoring, pending the ongoing prospective studies cited in this review.

Anti-Tumor Immunity and Preoperative Radiovaccination: Emerging New Concepts in the Treatment of Breast Cancer

Neoadjuvant chemotherapy (NACT) for certain breast cancer (BC) subtypes confers significant tumor regression rates and a survival benefit for patients with a complete pathologic response. Clinical and preclinical studies have demonstrated that immune-related factors are responsible for better treatment outcomes, and thus, neoadjuvant immunotherapy (IO) has emerged as a means to further improve patient survival rates. Innate immunological "coldness", however, of specific BC subtypes, especially of the luminal ones, due to their immunosuppressive tumor microenvironment, hinders the efficacy of immune checkpoint inhibitors. Treatment policies aiming to reverse this immunological inertia are, therefore, needed. Moreover, radiotherapy (RT) has been proven to have a significant interplay with the immune system and promote anti-tumor immunity. This "radiovaccination" effect could be exploited in the neoadjuvant setting of BC and significantly enhance the effects of the already established clinical practice. Modern stereotactic irradiation techniques directed to the primary tumor and involved lymph nodes may prove important for the RT-NACT-IO combination. In this review, we provide an overview and critically discuss the biological rationale, clinical experience, and ongoing research underlying the interplay between neoadjuvant chemotherapy, anti-tumor immune response, and the emerging role of RT as a preoperative adjunct with immunological therapeutic implications in BC.

The Role of Radiotherapy for Patients with Unresectable Locally Advanced Breast Cancer following Neoadjuvant Systemic Therapy

Background

For locally advanced breast cancer (LABC) patients who remained unresectable after neoadjuvant systemic therapy (NST), radiotherapy (RT) is considered as an approach for tumor downstaging. In this study, we attempted to discuss the value of RT for patients with unresectable or progressive disease in the breast and/or regional nodes following NST.

Methods

Between January 2013 and November 2020, the data for 71 patients with chemo-refractory LABC or de novo bone-only metastasis stage IV BC who received locoregional RT with or without surgical resection were retrospectively analyzed. Factors associated with tumor complete response (CR) were recognized using logistic regression. Locoregional progression-free survival (LRPFS) and progression-free survival (PFS) were calculated using the Kaplan-Meier method. The Cox regression model was applied to recognize the recurrence risk factors.

Results

After RT, 11 patients (15.5%) achieved total cCR. Triple-negative subtype (TNBC) was associated with a lower total cCR rate compared with other subtypes (p = 0.033). 26 patients proceeded to surgery, and the operability rate was 36.6%. 1-year LRPFS and PFS were 79.0% and 58.0%, respectively, for the entire cohort. Surgical cases had an improved 1-year LRPFS (p = 0.015), but not 1-year PFS (p = 0.057), compared with definitive RT cases. Non-any cCR was the most prominent predictor of a shorter LRPFS (p < 0.001) and PFS (p = 0.002) in the multivariate analysis. Higher TNM stage showed a trend toward a shorter LRPFS time (p = 0.058), and TNBC (p = 0.061) showed a trend toward a shorter PFS interval.

Conclusions

This study demonstrated that RT was an effective tumor downstaging option for chemo-refractory LABC. For patients with favorable tumor regression, surgery following RT might bring survival benefits.

Preoperative radiotherapy: A paradigm shift in the treatment of breast cancer? A review of literature

The standard of care for early-stage breast cancer (BC) consists of breast-conserving surgery followed by postoperative irradiation. Recently, the concept of changing the usual sequence of treatment components in BC RT has been investigated. Potential advantages of preoperative RT in BC include a possible tumor downstaging with improved surgical cosmetic outcomes, accurate tumor site identification and better target volume delineation. Furthermore, preoperative RT could serve as a tool for treatment stratification for de-escalation of treatments in the event of pathological complete response. The present literature review analyzed the available clinical data regarding the potential impact of preoperative RT. Overall, available clinical evidence of preoperative RT in BC remains limited, deriving mostly from retrospective case series. Nevertheless, the experiences prove the feasibility of the preoperative RT approach and confirm the efficacy in almost all analyzed studies, including experiences using higher prescription RT doses or RT in combination with systemic therapy.

A phase 2 study of capecitabine and concomitant radiation in women with advanced breast cancer

PURPOSE

To examine the response rate of gross chemo-refractory breast cancer treated with concurrent capecitabine (CAP) and radiation therapy in a prospective Phase II study.

METHODS AND MATERIALS

Breast cancer patients with inoperable disease after chemotherapy, residual nodal disease after definitive surgical resection, unresectable chest wall or nodal recurrence after a prior mastectomy, or oligometastatic disease were eligible. Response by RECIST criteria was assessed after 45 Gy. Conversion to operable, locoregional control, and grade ≥3 toxicities were assessed. The first 9 patients received CAP 825 mg/m2 twice daily continuously. Because of toxicity, subsequent patients received CAP only on radiation days. Kaplan-Meier analysis was used to estimate overall survival (OS) and locoregional recurrence-free survival.

RESULTS

From 2009 to 2012, 32 patients were accrued; 26 received protocol-specified treatment. Median follow-up was 12.9 months (interquartile range, 7.10-42.9 months). Nineteen patients (73%) had partial or complete response. Fourteen patients (53.9%) experienced grade 3 non-dermatitis toxicity (7 of 9 continuous dosing). Three of four inoperable patients converted to operable. One-year actuarial OS in the treated cohort was 54%. The trial was stopped early after interim analysis suggested futility independent of response. Treatment was deemed futile (ie, conversion to operable but M1 disease immediately postoperatively) in 9 of 10 patients with triple-negative (TN) versus 6 of 16 with non-TN disease (P=.014). Median OS and 1-year locoregional recurrence-free survival among non-TN versus TN patients was 22.8 versus 5.1 months, and 63% versus 20% (P=.007).

CONCLUSIONS

Capecitabine can be safely administered on radiation days with careful clinical monitoring and was associated with encouraging response in this chemo-refractory cohort. However, patients with TN breast cancer had poor outcomes even when response was achieved. Further study in non-TN patients may be warranted.

Primary systemic therapy and whole breast irradiation for locally advanced breast cancer: a systematic review

The current management of locally advanced breast cancer (LABC) is based on tri-modality treatment including chemotherapy, radiotherapy and surgery. The concept of preoperative concurrent or sequential chemoradiation for LABC was initially reported more than a decade ago; however this concept did not gain popularity because of the low benefit/risk ratio and the lack of strong data supporting the concept. The purpose of the current systematic review was to explore the published data about preoperative chemoradiation (sequential and/or concurrent) using whole breast irradiation in terms of toxicity and outcome.