[Results of 10 years of a randomized trial of neoadjuvant chemotherapy in breast cancers larger than 3 cm]

Dynamics of circulating microRNAs as a novel indicator of clinical response to neoadjuvant chemotherapy in breast cancer

Background

Circulating microRNAs (miRNAs) have been indicated as predictive biomarkers in breast cancer. We aimed to explore the association of plasma miRNA dynamics with response to neoadjuvant chemotherapy (NCT) and disclose early markers for predicting sensitivity.

Methods

One hundred and nine patients with operable or locally advanced breast cancer, who participated in a prospective clinical trial and received NCT, were analyzed. Blood samples were collected before random assignment, after two cycles of chemotherapy (C2) and before surgery. Based on their clinical response, the patients were defined as chemo‐sensitive or insensitive. First, baseline and preoperative samples of selected cases from both groups were screened via TaqMan miRNA array for candidate miRNAs. Afterward all the biospecimens were tested for the candidate miRNAs (miR‐222, miR‐20a, miR‐451, miR‐9, miR‐34a, miR‐155, and miR‐145) by quantitative real‐time PCR. Finally, logistic regression model was utilized to determine the predictive value of baseline/C2 expression of these miRNAs.

Results

Based on the results of microRNA profiling, seven miRNAs were selected for further validation. In the HR+/HER2‐ cohort (n = 51) dynamics of three miRNAs, including miR‐222, miR‐20a, and miR‐451, were associated with chemo‐sensitivity. Importantly, across all the three subtypes we consistently identified chemo‐induced decrease in plasma miR‐34a in the insensitive patients. Finally, baseline miR‐222 overexpression (OR = 6.422, P = 0.049), C2 miR‐20a up‐regulation (OR = 0.144, P = 0.021) and C2 miR‐451 down‐regulation (OR = 8.213, P = 0.012) were predictive markers of response to NCT in HR+/HER2‐ breast cancer.

Conclusions

We described that dynamics of circulating miRNAs might help predict clinical response to NCT in breast cancer.

Pure and predominantly pure intralymphatic breast carcinoma after neoadjuvant chemotherapy: an unusual and adverse pattern of residual disease

Neoadjuvant chemotherapy is standard of care for patients with locally advanced breast cancer. Patients who achieve a pathologic complete response have a more favorable outcome than those who do not; however, a standard system for classifying residual disease has not been adopted. Various definitions of complete response exist, some of which allow for minimal residual invasive or in situ carcinoma. The pattern of residual carcinoma restricted to lymphatic spaces without stromal invasion, herein called pure intralymphatic carcinoma, has not been well addressed. Neither has the pattern of minimal residual stromal invasive cancer accompanied by an extensive intralymphatic component, herein called predominantly pure intralymphatic carcinoma. We report the incidence, clinicopathologic features, and clinical significance of pure and predominantly pure intralymphatic carcinoma in a cohort of 146 neoadjuvant-treated breast cancer patients. We also evaluate the use of the immunohistochemical lymphatic marker D2-40 in these tissues exposed to neoadjuvant chemotherapy. Six patients (4%) had residual pure intralymphatic carcinoma. No gross abnormalities were present in the mastectomy specimens except for 1 case that had a discrete mass, corresponding to residual in situ carcinoma. Residual intralymphatic tumor size ranged from 0.2 to 6 cm. All but one had residual positive lymph nodes. Residual predominantly pure intralymphatic carcinoma was found in 5/146 (4%) patients. A discrete gross mass was observed in 3/5 specimens. Whereas residual stromal invasive carcinoma ranged in size from 0.1 to 1.8 cm, the intralymphatic component ranged from 6 to 9.3 cm. All had residual positive lymph nodes. D2-40 adequately marked lymphatic endothelium in all cases tested. Death occurred in 6/11 (55%) versus 17/135 (13%) patients with or without pure/predominantly pure intralymphatic carcinoma, respectively. After controlling for tumor stage, the presence of either of these residual intralymphatic patterns was associated with a 3-fold increase in death (Cox proportional hazards ratio=3.59, 95% confidence interval, 1.29, 9.99, P=0.014). Elevated risk for disease progression was also observed but this was not statistically significant. We conclude that pure/predominantly pure intralymphatic carcinoma is a clinically significant pattern of residual disease. This may be an underrecognized pattern because of the discordance between gross and microscopic findings and because of challenges in diagnosing intralymphatic carcinoma. D2-40 immunostaining is useful in this setting. Current staging criteria should be clarified to define whether extensive intralymphatic tumor should be incorporated in tumor stage assignment.

Neoadjuvant versus adjuvant systemic treatment in breast cancer: a meta-analysis

BACKGROUND

Interest in the use of preoperative systemic treatment in the management of breast cancer has increased because such neoadjuvant therapy appears to reduce the extent of local surgery required. We compared the clinical end points of patients with breast cancer treated preoperatively with systemic therapy (neoadjuvant therapy) and of those treated postoperatively with the same regimen (adjuvant therapy) in a meta-analysis of randomized trials.

METHODS

We evaluated nine randomized studies, including a total of 3946 patients with breast cancer, that compared neoadjuvant therapy with adjuvant therapy regardless of what additional surgery and/or radiation treatment was used. Fixed and random effects methods were used to combine data. Primary outcomes were death, disease progression, distant disease recurrence, and loco-regional disease recurrence. Secondary outcomes were local response and conservative local treatment. All statistical tests were two-sided.

RESULTS

We found no statistically or clinically significant difference between neoadjuvant therapy and adjuvant therapy arms associated with death (summary risk ratio [RR] = 1.00, 95% confidence interval [CI] = 0.90 to 1.12), disease progression (summary RR = 0.99, 95% CI = 0.91 to 1.07), or distant disease recurrence (summary RR = 0.94, 95% CI = 0.83 to 1.06). However, neoadjuvant therapy was statistically significantly associated with an increased risk of loco-regional disease recurrences (RR = 1.22, 95% CI = 1.04 to 1.43), compared with adjuvant therapy, especially in trials where more patients in the neoadjuvant, than the adjuvant, arm received radiation therapy without surgery (RR = 1.53, 95% CI = 1.11 to 2.10). Across trials, we observed heterogeneity in the rates of complete clinical response (range = 7%-65%; P for heterogeneity of <.001), pathologic response (range = 4%-29%; P for heterogeneity of <.001), and adoption of conservative local treatment (range = 28%-89% in neoadjuvant arms, P for heterogeneity of <.001).

CONCLUSIONS

Neoadjuvant therapy was apparently equivalent to adjuvant therapy in terms of survival and overall disease progression. Neoadjuvant therapy, compared with adjuvant therapy, was associated with a statistically significant increased risk of loco-regional recurrence when radiotherapy without surgery was adopted.

Breast conservation therapy (BCT): surgery as the cornerstone of multi-specialty care

Surgical care has been the mainstay of breast cancer diagnosis and treatment. As care has evolved, increased collaborative approaches among surgeons, radiologists, radiation oncologists and medical oncologists have improved the quality of breast cancer treatment for the patient. Breast conservation therapy (BCT) exemplifies how multi-specialty care can increase cancer cure rates at the same time that the disfiguring aspects of breast cancer treatment can be minimized. New questions are being raised within clinical forums about how to do better both for the patient and for her oncologic treatment. The following questions represent three current issues in BCT: 1. What general operative approaches in BCT can minimize morbidity and optimize the cosmetic outcome from surgery? 2. What role does radiation therapy play in BCT for invasive and non-invasive breast cancer to supplement surgical intervention? 3. What role can neoadjuvant chemotherapy play in improving BCT rates?