Long-term outcomes and predictors of recurrence in node-negative early stage breast cancer patients

BACKGROUND

We evaluated the outcomes, and risk factors for recurrence in patients with early stage node-negative breast cancer in this study.

METHOD

Retrospective data analysis was done on patient treatment records from 1988 to 2018. The patient's demographic, clinical, pathological, and therapeutic characteristics were noted. To evaluate survival analysis and predictors of recurrence, we employed Kaplan-Meier analysis with the log-rank test.

RESULTS

A total of 357 patients in all were enrolled in the research. At the time of diagnosis, the median age was 50 (with a range of 18-81). A total of 85.5% of patients had undergone a lumpectomy, while 14.5% had a mastectomy. 78.7% of patients had sentinel lymph node biopsy, and 21.3% had axillary lymph node dissection. In addition, the patients received adjuvant radiotherapy (88.7%), adjuvant endocrine therapy (82.1%), and adjuvant chemotherapy (48.5%). Recurrence of the tumor occurred in 31 (8.7%) patients (local recurrence 45.2% and metastatic disease 54.8%). Ten- and twenty-year recurrence-free survival rates were 92% and 77%. 19 (5.3%) patients had also developed contralateral breast cancer. Ten-year survival rates were 91.6%, and 20-year survival rates were 76.6%, respectively. Aged over 65 years (p = 0.004), necrosis (p = 0.002), mitosis (p = 0.003), and nuclear pleomorphism (p = 0.049) were found as statistically significant factors for recurrence in univariate analysis. In the ROC analysis, the largest size of the tumor (over 1.45 cm, p = 0.07) remained outside the statistical significance limit in terms of recurrence.

CONCLUSIONS

Thirty-year outcomes in individuals with early stage, node-negative breast cancer were shown in this study. We found that the recurrence ratios between 10 and 20 years were more frequent than the first 10 years during the follow-up. Despite the small number of patients who experienced a recurrence, we demonstrated that, in univariate analysis, being older than 65 and having some pathological characteristics (nuclear pleomorphism, mitosis, and necrosis) were statistically significant factors for disease recurrence.

Diverging prognostic effects of CD155 and CD73 expressions in locally advanced triple-negative breast cancer

Background

Immune checkpoint inhibition, combined with novel biomarkers, may provide alternative pathways for treating chemotherapy-resistant triple-negative breast cancer (TNBC). This study investigates the expression of new immune checkpoint receptors, including CD155 and CD73, which play a role in T and natural killer (NK) cell activities, in patients with residual TNBC after neoadjuvant chemotherapy (NAC).

Methods

The expression of biomarkers was immunohistochemically examined by staining archival tissue from surgical specimens (n = 53) using specific monoclonal antibodies for PD-L1, CD155, and CD73.

Results

Of those, 59.2% (29/49) were found to be positive (>1%) for PD-L1 on the tumour and tumour-infiltrating lymphocytes (TILs), while CD155 (30/53, 56.6%) and CD73 (24/53, 45.3%) were detected on tumours. Tumour expressions of CD155 and CD73 significantly correlated with PD-L1 expression on the tumour (p = 0.004 for CD155, p = 0.001 for CD73). Patients with CD155 positivity ≥10% were more likely to have a poor chemotherapy response, as evidenced by higher MDACC Residual Cancer Burden Index scores and Class II/III than those without CD155 expression (100% vs 82.6%, p = 0.03). At a median follow-up time of 80 months (range, 24-239), patients with high CD73 expression showed improved 10-year disease-free survival (DFS) and disease-specific survival (DSS) rates compared to those with low CD73 expression. In contrast, patients with CD155 (≥10%) expression exhibited a decreasing trend in 10-year DFS and DSS compared to cases with lower expression, although statistical significance was not reached. However, patients with coexpression of CD155 (≥10%) and low CD73 were significantly more likely to have decreased 10-year DFS and DSS rates compared to others (p = 0.005).

Conclusion

These results demonstrate high expression of CD73 and CD155 in patients with residual tumours following NAC. CD155 expression was associated with a poor response to NAC and poor prognosis in this chemotherapy-resistant TNBC cohort, supporting the use of additional immune checkpoint receptor inhibitor therapy. Interestingly, the interaction between CD155 and CD73 at lower levels resulted in a worse outcome than either marker alone, which calls for further investigation in future studies.

Ozone therapy as a novel complementary therapeutic approach in refractory idiopathic granulomatous mastitis

Background

Autoimmunity may play a major role in the pathogenesis of idiopathic granulomatous mastitis (IGM). The therapeutic potential of ozone therapy has recently been shown in rheumatological diseases, and this study aimed to assess the clinical efficacy of ozone therapy (OT) in refractory IGM.

Methods

Patients with biopsy-verified IGM and incomplete response after steroid therapy (n = 47) between 2018 and 2021 were enrolled. Of these, 23 cases in cohort A had standard treatment with further steroid therapy (ST), and 24 were treated with systemic OT via autohemotherapy (AHT) in addition to steroid therapy (cohort B).

Results

The median age was 33 years (range, 24-45). Patients in cohort B had a higher complete response rate after completion of a four-month ozone therapy than those in the ST-group (OT-group, 37.5% vs. ST-group, 0%; p = 0.002). At a median follow-up of 12 months (range, 12-35), the patients treated with OT had a lower one-year recurrence in the affected breast than cases in cohort A treated with ST (OT-group, 21% vs. ST-group, 70%; p = 0.001). No significant side effects were observed in patients in cohort B related to AHT. Furthermore, OT significantly decreased the total steroid treatment duration (median week of steroid use; 26  weeks in cohort A vs. 12 weeks in cohort B; p = 0.001).

Conclusion

Systemic OT increases the complete response rate and decreases the duration of steroid treatment in patients with refractory IGM. Therefore, ozone therapy is an effective, well-tolerated, and safe novel complementary therapeutic modality.

Evaluation of Benign Breast Diseases With or Without Atypical Epithelial Hyperplasia Accompanying Radial Scars

Objective:

A radial scar (RS) is a benign breast lesion (BBL) that has an obscure etiology. RS is easily confused with breast carcinoma and therefore correct identification radiologically and pathologically is important. The aim of this study was to determine the incidence of atypical lesions by evaluating RS detected with BBL and to investigate whether atypia and RS are related to their characteristics.

Materials and Methods:

A total of 1.370 patients with a diagnosis of BBL postoperatively in a single department were analyzed retrospectively. Forty-six confirmed RS/complex sclerosing lesion (CSL) cases were selected. The demographic and clinical characteristics of the patients and the relationship between RS and other BBL were evaluated. In addition, the relationship between RS/CSL and the presence of atypia was interpreted.

Results:

The mean age was 45.17±8.72 years. Spiculated lesion (34.8%) on mammography and microcalcification (37%) on histopathological examination were the most common features. The most common BBL accompanying RS/CSL was adenosis. Atypical epithelial hyperplasia (AEH) was presented in 15 (32.6%) of those diagnosed with RS. Although all patients were benign, the frequency of AEH accompanying RS was found to be significantly higher. The mean size of RS was 10.8±8.4 mm (2-30 mm). The size of RS/CSL was not significantly associated with atypia.

Conclusion:

RS/CSLs usually present as suspicious lesions that must be distinguished radiologically from malignancy. However RS, which can be present with malign breast lesions, can be also seen with all BBL. Therefore, core biopsy and/or excisional biopsy continue to be important for definitive histopathological diagnosis.

A Hypofractionated Radiotherapy Schedule with a Simultaneous Integrated Boost for Breast Cancer: Outcomes including Late Toxicity and Health Quality

Introduction: This study aimed to evaluate the long-term adverse effects on the physical appearance and overall well-being of breast cancer patients who receive hypofractionated radiotherapy as whole breast and simultaneous integrated boost (SIB) treatment, utilizing intensive modulated radiotherapy (IMRT), volumetric modulated arc therapy (VMAT), or a hybrid therapy approach. Material/Methods: This investigation involved administering hypofractionated SIB-VMAT therapy to individuals diagnosed with early-stage breast cancer. Treatment was carried out over a three-week period in which a total dose of 48.06 Gy was given to the entire breast and 54 Gy was given to the tumor bed. Data on skin toxicity and cosmetic outcomes were analyzed both during the acute phase and during the three-month and five-year follow-up periods after treatment. Results: A total of 125 patients treated between December 2014 and December 2016 were included in the study. The data of these patients with at least 5 years of follow-up were analyzed. Conclusions: Considering these long-term results, hypofractionated SIB-VMAT can be considered a viable treatment choice, even for patients with unfavorable conditions.

Is Breast Conserving Surgery Efficacious in Breast Cancer Patients with BRCA1 or BRCA2 Germline Mutation?

Background

The optimal surgical therapy for newly diagnosed breast cancer with germline mutations in susceptibility genes is still uncertain for many physicians. In this study, we aimed to determine the efficacy of breast conserving surgery (BCS) in breast cancer patients with BRCA1 or BRCA2 mutation by assessing its outcomes and locoregional recurrence (LR) rates.

Materials and Methods

Seventy-five patients operated with BCS or mastectomy for breast cancer between 2006 and 2017 and had BRCA1 or BRCA2 mutation were included in the study. Effects of the performed breast surgery and clinicopathological characteristics on surgical outcomes, LR rates and survival were analyzed with showing the distribution of BRCA1 and BRCA2 germline mutations.

Results

The median age of the patients was 42 years (20-77). BRCA1 mutations were found in 46 (61.3%) patients and BRCA2 mutations in 29 (38.7%) patients. Compared to BRCA2 carriers, BRCA1 carriers were more likely to have higher tumor grade (84.8% vs 44.8%; p = 0.001) and non-luminal subtype tumors (67.4% vs 13.8%; p = 0.001). A total of 44 (58.7%) patients underwent unilateral mastectomy and 31 (41.3%) patients underwent BCS. At a median follow-up time of 60 (12-240) months, LR was observed in 6 patients equally divided in both BCS and mastectomy groups. LR rates were slightly higher after BCS versus mastectomy (9.7% and 6.8%, respectively). Additionally, there were no statistically significant differences in disease-free survival (DFS) and disease-specific survival (DSS) rates after 10 years in the BCS group versus the mastectomy group (p = 0.117 and 0.109, respectively), but in fact, the rates were better in the BCS group.

Conclusion

Our findings indicate that BCS may serve as an efficacious alternative to mastectomy for breast cancer patients with BRCA1 or BRCA2 mutation. Additionally, tumor size, lymph node positivity, and TNM stage should be taken into consideration for a better surgical decision-making.

Ozone therapy restores immune dysfunction in refractory idiopathic granulomatous mastitis as a novel potential therapeutic approach

Immunological dysfunction has been suggested to play a major role in the pathogenesis of idiopathic granulomatous mastitis (IGM). We recently showed that ozone therapy was effective in patients with steroid-resistant IGM. This study assessed alterations in intracellular cytokine expression patterns in different T-lymphocyte subsets after ozone therapy in refractory IGM. Peripheral blood T lymphocyte subsets (CD8⁺ , CD4⁺ , CD4⁺ CD25⁺ CD127^- ) were analyzed via flow-cytometry for intracellular cytokine expressions IFN-γ, TNF-α, IL-10, and TGF-β before and after completion of 4-month systemic ozone therapy. Ozone therapy significantly increased the CD4⁺ IFN-γ⁺ (p = 0.032), CD4⁺ TNF-α⁺ (p = 0.028), and the CD8⁺ TNF-α⁺ (p = 0.012) T cells. In contrast, significant decreases in CD4⁺ IL-10⁺ (p = 0.047) and CD8⁺ IL-10⁺ T cells (p = 0.022) and CD4⁺ CD25⁺ CD127^-//low Treg cells secreting TGF-β (p = 0.005) were found after ozone therapy. When patients were analyzed according to the response to ozone therapy, patients with a complete remission were more likely to have increased CD3^- CD16⁺ CD56⁺ natural killer cells (p = 0.0027) and decreased CD19⁺ B lymphocytes (p = 0.046) following ozone therapy. Our results suggest that ozone therapy stimulated a T-helper-1 response associated with IFN-γ production and downregulation of TGF-β expression in CD4⁺ CD25⁺ CD127^- Treg cells. These alterations in the immune system following ozone therapy can improve wound healing and restore immune dysfunction in patients with refractory IGM.

High co-expression of immune checkpoint receptors PD-1, CTLA-4, LAG-3, TIM-3, and TIGIT on tumor-infiltrating lymphocytes in early-stage breast cancer

High expression of immune checkpoint receptors (ICRs) in the tumor microenvironment regulates the anti-tumor response. In this study, the differential expressions of ICRs on tumor-infiltrating lymphocytes (TILs) in patients with early-stage breast cancer were investigated.The study included 32 patients who underwent surgery with a diagnosis of early-stage breast cancer between September 2018 and March 2020. TIL isolation was performed using a MACS tumor separation device and tumor separation kit. PD-1, CTLA-4, LAG-3, TIM-3, and TIGIT expression of cytotoxic T and natural killer (NK) cells on TILs and peripheral blood lymphocytes (PBLs) were determined by flow cytometry.Patients with a high Ki-67 index, high TIL density, and HER-2 positivity were more likely to have increased CD16⁺CD56^dim NK cells on TILs. Patients with T2 tumors were more likely to have increased expression of PD-1, LAG-3, and TIGIT on tumor-infiltrating CD8⁺ cytotoxic T cells than those with T1 tumors. PD-1, CTLA-4, TIGIT, LAG-3, and TIM-3 expression of CD8⁺ T and CD16^-CD56^bright NK cells in TILs showed significant positive correlations with each other. PD1⁺CD8⁺, TIGIT⁺CD16⁺, and CTLA-4⁺CD56⁺ cells in PBLs and TILs were found to be negatively correlated, whereas only TIM-3⁺ expression of CD8⁺ T and CD16⁺CD56^dim cells in PBLs and TILs showed positive correlations.Our results suggest that CD16⁺CD56^dim NK cells on TILs may play a major role in the immune response against HER2-positive or highly proliferating breast tumors in patients with early-stage breast cancer. Furthermore, various ICRs were found to be highly co-expressed with each other on TILs, including PD-1, CTLA-4, LAG-3, TIM-3, and TIGIT. These receptors may synergistically suppress the response to the tumor, which may trigger immune escape mechanisms in the early stage of carcinogenesis. However, ICR expressions other than TIM3 on PBLs were not found to accompany their counterparts on TILs.

Abbreviated and Standard Breast MRI in Neoadjuvant Chemotherapy Response Evaluation: A Comparative Study

OBJECTIVES

To investigate the efficacy of abbreviated breast magnetic resonance imaging (MRI) in neoadjuvant chemotherapy (NAC) response evaluation.

METHODS

MR images of 50 locally advanced breast cancer patients who underwent standard protocol (SP) breast MRI before and after NAC, were re-evaluated retrospectively. Abbreviated protocol (AP) was obtained by extracting images from SP and then evaluating them in a separate session. Protocols were compared with the histological findings after surgery as the reference standard.

RESULTS

A statistically significant difference was found between two protocols in response evaluation by the McNemar test (p=0.018). But, the Kappa value was 0.62 (p<0.001) which indicates substantial agreement. No statistically significant differences were found between the two protocols (AP and SP) and pathological results in the McNemar test (p=0.12, p=0.60, respectively). Kappa values were 0.48 (p<0.001), 0.60 (p<0.001), respectively which indicates moderate agreement for both protocols with higher values by SP evaluation. The residual maximum median diameters were smaller than the pathology, with both protocols (p<0.001).

CONCLUSION

Although statistical difference, there was a substantial correlation between the two protocols in response evaluation. Both protocols were moderately correlated with pathological results with slightly higher in SP. However, the residual maximum median diameters were smaller than the pathology, with both protocols. These results may limit the use of AP in evaluating the local extent of the tumor, especially in patients who will undergo breast-conserving surgery.

Abstract P1-01-07: Factors predicting a lower likelihood of residual nodal disease in clinically-node positive patients undergoing sentinel node surgery after neoadjuvant chemotherapy for breast cancer

Background: Residual nodal disease at the completion axillary lymph node dissection (ALND) has been reported in over 60% in patients with a positive sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NAC). This study aimed to explore whether any clinical or histopathological characteristics of patients may be associated with a lower likelihood of having non-SLN metastasis at ALND. Methods: Between January 2004 to January 2021, 459 patients with cT1-4/N1-3 underwent ALND due to a positive SLNB after NAC. Demographic, clinical and histopathological characteristics of patients were analyzed to predict the non-SLN metastasis at ALND. Sentinel lymph node ratio was defined as the ratio of the number of positive SLN to the total excised SLNs. Results: Median age was 47 (21-84). Of those, the majority of the patients had cT1-2 (67.8%) and cN1 disease (78.1%), whereas 76.5% of tumors were invasive ductal carcinoma. The frequency of non-SLN metastases according to the tumor subtypes were 59.5% in luminal A, 73.8% in HER2(-) luminal B, 60.3% in HER2(+) luminal B, 66.7% in non-luminal HER2(+), and 66.7% in triple negative breast carcinoma. Of those with removal more than 2 SLNs, having 1 positive SLN, or breast pathologic complete response, or cT1-2 disease , or a SLN ratio &lt;50% or low volume metastatic disease including isolated tumor cell (ITC)/micrometastasis were statistically less likely found to have a non-SLN metastasis (p&lt;0.05). Factors associated with a non-SLN involvement less than 40% were a SLN ratio &lt;50% (39.2%) and low volume metastatic disease (36.4%). Multivariate logistic regression analysis revealed a decreased likelihood for non-SLN metastasis at ALND for patients with cT1-2 (OR= 0.45; 95% CI: 0.25-0.82; p=0.009), ITC and micrometastasis (OR=0.24; 95% CI: 0.09-0.65; p=0.006), and a SLN-ratio &lt;50% ((OR=0.15; 95% CI: 0.08-0.26; p&lt;0.001). A subgroup of patients with cT1-2/N1 having a SLN ratio &lt;50% or ITC/micrometastasis were found to have 25.9% and 28.6% non-SLN positivity at ALND, respectively. Conclusions: In patients with a positive SLN after NAC, the likelihood of having residual disease at ALND was high across all tumor subtypes and clinical patient and tumor characteristics. However, the residual nodal disease rate was found to be lower than 30% in carefully selected patient subgroups with cT1-2/N1 along with ITC/micrometastasis or a SLN ratio &lt;50% (Table 1) . These results suggest omission of ALND could be considered in meticulously selected patients with cT1-2 and low volume metastatic disease as long as axillary radiation and effective systemic treatment provided Table 1. Factors associated with non-SLN metastasis at ALND

FactorsOR(95%CI)p-valuecT0.009*1&20.45(0.25-0.82)3&4Reference (1)SLN Status0.006*ITC and micrometastasis0.24(0.09-0.65)MacrometastasisReference (1)SLN-Ratio (%)&lt;0.001*&lt;50%Reference(1)≥50%0.15(0.08-0.26)*:p&lt;0.05, Logistic regression(enter method), OR:Odds Ratio; Dependent variable:Non-SLN positivity

Citation Format: Neslihan Cabioglu, Hasan Karanlık, Abdullah Igci, Mahmut Muslumanoglu, Mustafa Tukenmez, Selman Emiroglu, Enver Ozkurt, Semen Onder, Pinar Saip, Yesim Eralp, Adnan Aydiner, Ekrem Yavuz, Vahit Ozmen. Factors predicting a lower likelihood of residual nodal disease in clinically-node positive patients undergoing sentinel node surgery after neoadjuvant chemotherapy for breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-01-07.

Primary Surgery with Systemic Therapy in Patients with de Novo Stage IV Breast Cancer: 10-year Follow-up; Protocol MF07-01 Randomized Clinical Trial

BACKGROUND

The aim of this randomized clinical trial was to evaluate the overall survival (OS) data of patients diagnosed with de novo stage IV breast cancer (BC) who received locoregional treatment (LRT) over a 10-year follow-up.

STUDY DESIGN

The MF07-01 is a 1:1 multicenter, randomized clinical trial comparing the LRT with systemic therapy (ST), where ST was given to all patients either immediately after randomization or after surgical resection of the intact primary tumor.

RESULTS

A total of 278 patients were randomized and 265 patients were in the final analysis. At 10-year follow-up, survivals were 19% (95% CI 13%-28%) and 5% (95% CI 2%-12%) in the LRT group and ST group, respectively. Median survival was 46 months for the LRT group and 35 months for the ST group, and hazard of death was 29% lower in the LRT group compared with the ST group (hazard ratio [HR] 0.71; 95% CI 0.59-0.86; p = 0.0003).

CONCLUSIONS

Patients with a diagnosis of de novo stage IV BC who underwent LRT followed by ST had a 14% higher chance of OS by the end of the 10-year follow-up compared with the patients who received only ST. The longer study follow-up revealed that LRT should be presented to patients when discussing treatment options.

Differential Expression of Novel Immune Checkpoint Receptors on Tumor Infiltrating Lymphocytes in Patients with Locally Advanced Breast Cancer after Neoadjuvant Chemotherapy

Immune checkpoint receptors (ICRs) were recently found to modulate the anti-tumoral immune response. This study aimed to determine the clinical and pathological associations of ICRs expression on tumor-infiltrating lymphocytes (TILs) in patients with locally advanced breast cancer (LABC) treated with neoadjuvant chemotherapy (NAC). Expressions of ICRs including PD-1, LAG-3, TIM-3, TIGIT, and CTLA-4 on CD8+ T lymphocytes and Natural Killer (NK) cells on TILs were analyzed by flow cytometry. Patients < 50 years were more likely to express CTLA-4 on CD8+ T lymphocytes compared to those ≥ 50 years (p = 0.004). In addition, patients with ypT3-4 tumors were more likely to have increased LAG-3 expression on CD16-CD56bright NK cells (p = 0.042) and PD-1 (p = 0.014) and CTLA-4 (p = 0.018) expressions on CD8+ T cells in regard to those with ypT1-T2, respectively. Contrarily, PD-1 expression on CD16-CD56bright NK cells was found to be decreased in patients with ypN+ compared to those with ypN- (p = 0.022). Furthermore, patients with HER2+ tumors were more likely to have increased TIM-3 expression on CD8+ T cells (p = 0.043), whereas patients with a better response to NAC were more likely to express TIGIT on CD8+ T (p = 0.014) and CD16- CD56bright NK cells (p = 0.003), respectively. The new generation ICRs, TIM-3, LAG-3, and TIGIT are highly expressed in LABC following NAC in patients with poor prognostic factors. Therefore, new evolving therapies using inhibitory mAbs directed to TIM-3, LAG-3, and TIGIT could be also be considered in locally advanced breast cancers expressing these ICRs.

Abstract PS1-26: Sentinel lymph node biopsy alone in locally advanced breast cancer after neoadjuvant chemotherapy: Turkish multicentric neosenti-turk MF-18-02-study

BACKGROUND: Omitting axillary lymph node dissection (ALND) following sentinel lymph node biopsy (SLNB) in patients with locally advanced breast cancer (LABC) after neoadjuvant chemotherapy (NAC) is still controversial. In this study, we evaluated factors affecting local recurrence and outcome in patients with LABC, who underwent SLNB alone after NAC. METHODS: Between 2004 to 2018, 320 patients with clinically node-positive LABC who received NAC and underwent SLNB alone after negative axillary staging were analyzed. All patients had breast and/or regional nodal irradiation. RESULTS: Median age was 46 (23-70). Of those, 228 patients had ypN0 disease (71.25%), whereas 92 patients had ypN(+) disease including 19 (20.6%) isolated tumor cells (ITC), 33 micrometastasis (35.9%) and 40 macrometastases (43.5%). At a median follow-up of 37 months (24-172), one patient (0.3%) with macrometastatic SLN having extracapsular extension was found to have locoregional recurrence at the 60th month. Five-year disease-free survival (DFS) and disease specific survival (DSS) rates were found as 87% and 95%, respectively. Patients with cT3&4 (HR=2.22, 95% CI; 1.07-4.62), non-luminal molecular pathology (HR=2.71, 95% CI, 1.23-5.97), and non-pCR in the breast (HR=2.21, 95% CI, 0.94-5.17) were found to have an increased HR compared to others in 5-year DFS. However, no significant differences could be found between patients ypN0, ypN-ITC&micrometastasis and ypN-macrometastasis regarding 5-year DFS and DSS rates. CONCLUSIONS: ALND could be safely avoided in selected patients with LABC who underwent SLNB after NAC having cT1-2, luminal pathology, breast and/or nodal pCR or low volume nodal disease, as long as axillary radiotherapy is provided.

Citation Format: Neslihan Cabioglu, Hasan Karanlık, Mahmut Muslumanoglu, Guldeniz Karadeniz Çakmak, Didem Can Trablus, Mustafa Tukenmez, Yeliz E. Ersoy, Cihan Uras, Baha Zengel, Selman Emiroğlu, Ayfer Kamalı Polat, Levent Yeniay, Enver Ozkurt, Halil Kara, Kamuran Ibis, Adnan Aydiner, Vahit Ozmen, Abdullah Igci. Sentinel lymph node biopsy alone in locally advanced breast cancer after neoadjuvant chemotherapy: Turkish multicentric neosenti-turk MF-18-02-study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-26.

Abstract PS4-32: Tim3 expression on tumor infiltrating lymphocytes is associated with poor response to neoadjuvan chemotherapy in patients with locally advanced triple negative breast cancer

Background: Expression of immune checkpoint receptors (ICR) on tumor infiltrating lymphocytes (TILSs) is associated with better response to immunotherapies via immune checkpoint inhibitors. Therefore, we investigated various ICR expressions on TILs in patients with locally advanced triple negative breast cancer (TNBC) after neoadjuvant chemotherapy (NAC). Methods: Expressions of ICRs were examined immunohistochemically by staining surgical specimen (n=61) using specific monoclonal antibodies for PDL-1, PD-1, TIM-3, LAG-3, CTLA-4. Positivity was defined staining &gt;1% on TILs. Results: Median age was 49 (24-76) years. The majority patients were clinically T3-4 (n=31, 50.8%), and clinically N1-3 (n=58, 95.1%) before NAC. Of those, 82% were found to have CTLA-4 positivity, whereas TILs associated positivites for PD1, PDL-1, LAG3 and TIM-3 were 62.3%, 50.9%, 26.2%, 68.9%. High expression of CTLA-4 was found to be associated with a better chemotherapy response (OR=7.94, 95%CI: 0.9-70.12, p=0.06), whereas TIM-3 positivity was contrarly associated with a worse chemotherapy response (OR=0.253, 95%CI: 0.066-0.974, p=0.047) as measured by MDACC Residual Cancer Burden Index. At a 47-month follow-up, patients with ypN0 disease (DFS; HR=0.31, 95% CI: 0.12-0.83, p=0.02 and DSS; HR=0.21, 95% CI:0.07-0.62, p=0.005) and CTLA-4 high expression on TILs (DFS; HR=0.38, 95% CI=0.17-0.85, p=0.019 and DSS; HR=0.34, 95% CI:0.15-0.78, p=0.01) were found to have improved survival. Conclusions: These findings demonstrate that CTLA-4, PD-1, PDL-1 and TIM-3 were highly expressed in TNBC after NAC. Our results more favor an immuncheckpoint inhibitor therapy via CTLA-4 alone or in combination with other immune check point inhibitors against PDL-1 and/or TIM-3 in addition to NAC in advanced TNBC.

Citation Format: Neslihan Cabioglu, Semen Onder, Gizem Oner, Hüseyin Karatay, Mustafa Tukenmez, Mahmut Muslumanoglu, Abdullah Igci, Yesim Eralp, Adnan Aydiner, Pinar Saip, Ekrem Yavuz, Vahit Ozmen. Tim3 expression on tumor infiltrating lymphocytes is associated with poor response to neoadjuvan chemotherapy in patients with locally advanced triple negative breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS4-32.

Abstract 947: Differential expressions of immune check point receptors on tumor infiltrating lymphocytes after neo-adjuvant chemotherapy (NAC) in patients with locally advanced breast cancer (LABC)

Background: Recent advances in tumor biology and immune system have identified check points modulating the anti-tumoral immune response. This study aimed to determine immune check point expressions patients with locally advanced breast cancer to explore any associations between clinical and prognostic factors to show effectiveness of targeted therapies for these molecules.

Materials and Methods: This prospective study was carried out between September 2018 and November 2019 in the Department of General Surgery of Istanbul University Istanbul Faculty of Medicine Breast Unit. Twenty-four patients with LABC with a partial response to neoadjuvant chemotherapy (NAC) were included in the study. Tumor infiltrating lymphocytes (TILs) were isolated from the residual tumor burden separated from the surgical material with cell dissociation kit by using MACS tumor separation device. Expressions of immune checkpoints receptors including PD-1, LAG-3, TIM-3, TIGIT and CTLA-4 on CD8 T lymphocytes and Natural Killer (NK) cell subsets obtained from TIL were analyzed by using flow cytometry.

Results: TILs of patients &lt;50 years were more likely to express CTLA-4 on CD8−T lymphocytes in compared to patients ≥ 50 years (p= 0.004). In addition, patients with an initially advanced clinical tumor stage pT3-T4 were more likely to have increased LAG 3 expression on CD56+ NK cells and PD-1, CTLA-4 expression on CD8+ T cells in regards to pT1-T2 (p = 0.014, p = 0.018, p = 0.042; respectively). Contrarly, PD-1 expression on cytokine secreting CD56bright NK cells were found to be lower in patients with pN+ than those patients with pN- (p= 0.022). Interestingly, increased TIGIT, LAG-3, PD-1 and CTLA-4 expressions in CD16+ NK cells were demonstrated in patients with extensive intra-ductal component (p=0,024, p=0,003, p=0,032, p=0,013; respectively). However, HER2+ patients were more likely to have increased TIM-3 expressions on cytotoxic CD8- T cells compared to others (p = 0.043). Furthermore, TIGIT expressions in CD8+ T and CD56bright NK cells were significantly higher in patients with higher response to NAC (p = 0.014, p = 0.030; respectively). Finally, there was a significant correlation between pathological regression scores and CTLA-4 expressions of cytotoxic NK cells in Pearson analyses (p = 0.03).

Conclusion: Our results suggest that patients with a younger age and advanced tumor burden are more likely to benefit from immunotherapeutical approaches using immune check point inhibitors. Furthermore, combination of systemic chemotherapy with immunotherapy may increase the pathologic response rate in breast cancer patients.

Citation Format: Ayxan Abbasov, Esin Çetin, Neslihan Cabioglu, Baran Mollavelioglu, Semen Onder, Selman Emiroglu, Mustafa Tukenmez, Mahmut Muslumanoglu, Abdullah Igci, Gunnur Deniz, Vahit Ozmen. Differential expressions of immune check point receptors on tumor infiltrating lymphocytes after neo-adjuvant chemotherapy (NAC) in patients with locally advanced breast cancer (LABC) [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 947.

Abstract P5-04-24: Differential expression of novel immune checkpoint receptors expressed on tumor-infiltrating lymphocytes (TIL) in patients with early breast cancer

Introduction: High expression of immune checkpoint receptors in tumor microenvironment reduces antitumor immunity and cause immune evasion of tumor cells. In recent years, immunotherapy trials using PD-1 or PDL-1 inhibitors in advanced triple negative (TN) breast cancer evolved very rapidly. The differential expression of novel immune checkpoint receptors such as TIM-3, LAG-3 and TIGIT in addition to PD-1, and CTLA-4 on tumor infiltrating lymphocytes (TIL) in patients with early breast cancer was investigated.

Material and methods: TIL were isolated by using a Tumor Dissociation Kit from fresh tumoral tissue. Flow-cytometric analyses were performed by using CD8, CD16, CD56, PD-1, CTLA-4, TIM-3, LAG-3 and TIGIT specific monoclonal antibodies on isolated TIL. Correlations were estimated between biological and clinical characteristics of tumors and demographic features of patients and flow cytometric findings.

Results: Median age was 47 (range 28-68). There were 7 patients (35%) with HER2+ or triple negative tumors, whereas 13 patients (65%) had HER2 (-) luminal cancers. Our findings showed that patients younger than 45 years were more likely to express high levels of CTLA-4 (p=0.013) and TIGIT (p=0.007) on CD56+ natural killer (NK) cells and TIM-3 (p=0.043) on CD16+ lymphocytes (Table 1), whereas the other high expressions including LAG-3 (p=0,08) and TIM-3 (p=0.06) on CD56+ NK cells did not reach the statistical significance. Furthermore, patients with high Ki-67 proliferation index &gt;35% were found to express higher CTLA-4 (p=0.011) on CD16+ lymphocytes. Patients with Stage II disease expressed higher levels of PD-1 (p=0.018) and LAG-3 (p=0.04) on CD8+ cytotoxic T lymphocytes than patients with Stage I disease. Similarly, patients with lymph node metastasis had higher TIGIT (p=0.04) and PD-1 (p=0.05) levels on CD16+ and CD56+ lymphocytes, respectively. No other significant associations could be found between immune check receptors and other parameters.

Conclusion: Our results suggest TIL in patients with more advanced stages and younger than 45 years old are more likely to express higher levels of immune checkpoint receptors such as LAG-3, TIM-3, CTLA-4, TIGIT and PD-1. Interestingly, no difference could be found in immune checkpoint receptor expressions in TIL between patients with luminal and TN or HER2+, that would justify immunotherapeutical approaches in selected luminal breast cancers in future trials.

Table 1. Significant correlations between immune check point receptor expression and demographic and tumor features CD8PD1CD8LAG3CD16CTLA4CD16TIGITCD16TIM3CD56CTLA4CD56TIGITCD56PD1meanpmeanpmeanpmeanpmeanpmeanpmeanpmeanpAge&lt;45 (n:7)11.930.427120.40513.210.13212.290.3214.140.043150.01315.360.00710.290.905&gt;45 (n:13)9.739.699.049.548.548.087.8810.62Ki-67 (cut off %35)&lt;%35 (n:12)10.710.84711.710.26313.250.01110.920.69810.540.96911.920.18911.880.20312.040.153≥%35 (n:8)10.198.696.389.8810.448,388.448.19N stageN0 (n:13)10.120.69210.770.7819.810.4758.580.04710.270.8129,580.3419.960.5798.620.05N1 (n:7)11.211011.7914.0710.9312,2111.514StageStage 1 (n:5)5.10.0185.90.0447.40.17611.40.69311.20.7690.51312.50.3826.40.073Stage 2 (n:15)12.312.0311.5310.210.27119.8311.87

All statistical analyses were evaluated using the Mann Whitney U test.

Citation Format: Baran Mollavelioglu, Esin Aktas Cetin, Neslihan Cabioglu, Aykhan Abbasov, Semen Onder, Selman Emiroglu, Mustafa Tukenmez, Mahmut Muslumanoglu, Abdullah Igci, Gunnur Deniz, Vahit Ozmen. Differential expression of novel immune checkpoint receptors expressed on tumor-infiltrating lymphocytes (TIL) in patients with early breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-04-24.

Abstract P1-20-01: Primary surgery in patients with de novo stage IV BC; finalizing the protocol MF07-01 randomized clinical trial

Background. The MF07-01 trial is a multicenter randomized study comparing locoregional treatment (LRT) followed by systemic therapy (ST) with ST alone in de novo Stage IV breast cancer (BC) patients.

Aim: To evaluate and finalize the survival data of LRT in patients with the diagnosis of de novo Stage IV BC.

Methods. At initial diagnosis, patients were randomized 1:1 to either the LRT or ST group. All the patients were given ST either immediately after randomization or after surgical resection of the intact primary tumor. Continuous and categorical variable differences between LRT and ST groups were analyzed using t-test and Chi-square test, respectively. Overall survival (OS) and 5-year survival rates were compared using Kaplan-Meier log-rank tests. Univariate and multivariate Cox models were used to estimate hazard ratios, and logistic regession model used to estimate odds ratio.

Results. During more than 10 years follow-up, 23% of patients in LRT group and 8% of patients in ST group were alive. Median survival was 46 months for LRT (n=134) and 35 months for ST (n=131) [HR:0.71, 95%CI;0.59-0.86, p=0.0004]. Solitary bone metastasis patients’ median survival was 14 months longer in LRT group comparing ST group [HR:0.55, 95%CI; 0.35-0.86, p=0.008]; 16% of solitary bone metastasis patients in the LRT group were alive, but all patients died in the ST group. Patients younger than 55 lived longer compared the patients older than 55 [HR:0.67, 95%CI; 0.52-0.87, p=0.002], and 26% of hormone receptor positive patients were still alive in the LRT group comparing 10% in the ST group [HR:0.71, 95%CI; 0.58-0.88, p=0.002]. Regarding the patients who lived at least 5 years since randomization, LRT (p=0.003), hormone receptor positivity (p=0.004), Triple negative status (p=0.02), hormonotherapy (p=0.0001), bisphosphonates usage (p=0.03), and 2 or more organ metastases (p=0.004) were associated with OS in univariant analyses. However, in the multivariate model with significant baseline and clinical characteristics only LRT [OR= 1.58, p=0.03] was found to be significantly related with over 5 years of survival.

Conclusion. In the current analysis, patients at the diagnosis of de novo stage IV BC who underwent LRT followed by ST had a 58% higher chance to live at least 5 years compared to the patients who received only ST. Longer follow-up of the study discloses that LRT should be presented to patients when discussing treatment options.

ClinicalTrials.gov identifier number is NCT00557986

Citation Format: Atilla Soran, Vahit Ozmen, Serdar Ozbas, Hasan Karanlik, Mahmut Muslumanoglu, Abdullah Igci, Zafer Canturk, Zafer Utkan, Cihangir Ozaslan, Turkkan Evrensel, Cihan Uras, Erol Aksaz, Aykut Soyder, Umit Ugurlu, Cavit Col, Neslihan Cabioglu, Ergun Erdem, Gunay Gurleyik, Efe Sezgin. Primary surgery in patients with de novo stage IV BC; finalizing the protocol MF07-01 randomized clinical trial [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-20-01.

Randomized Trial Comparing Resection of Primary Tumor with No Surgery in Stage IV Breast Cancer at Presentation: Protocol MF07-01

BACKGROUND

The MF07-01 trial is a multicenter, phase III, randomized, controlled study comparing locoregional treatment (LRT) followed by systemic therapy (ST) with ST alone for treatment-naïve stage IV breast cancer (BC) patients.

METHODS

At initial diagnosis, patients were randomized 1:1 to either the LRT or ST group. All the patients were given ST either immediately after randomization or after surgical resection of the intact primary tumor.

RESULTS

The trial enrolled 274 patients: 138 in the LRT group and 136 in the ST group. Hazard of death was 34% lower in the LRT group than in the ST group (hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.49-0.88; p = 0.005). Unplanned subgroup analyses showed that the risk of death was statistically lower in the LRT group than in the ST group with respect to estrogen receptor (ER)/progesterone receptor (PR)(+) (HR 0.64; 95% CI 0.46-0.91; p = 0.01), human epidermal growth factor 2 (HER2)/neu(-) (HR 0.64; 95% CI 0.45-0.91; p = 0.01), patients younger than 55 years (HR 0.57; 95% CI 0.38-0.86; p = 0.007), and patients with solitary bone-only metastases (HR 0.47; 95% CI 0.23-0.98; p = 0.04).

CONCLUSION

In the current trial, improvement in 36-month survival was not observed with upfront surgery for stage IV breast cancer patients. However, a longer follow-up study (median, 40 months) showed statistically significant improvement in median survival. When locoregional treatment in de novo stage IV BC is discussed with the patient as an option, practitioners must consider age, performance status, comorbidities, tumor type, and metastatic disease burden.

Abstract P6-16-01: The importance of loco-regional tumor burden and surgery on survival in patients with de novo stage IV breast cancer; post-hoc analyses of protocol MF07-01

Background: The MF07-01 trial is a multicenter phase III randomized controlled trial of treatment naive stage IV BC patients comparing loco-regional surgery (LRS) followed by appropriate systemic therapy (ST) versus ST alone.

Aims: To evaluate the importance of loco-regional tumor burden and surgery on overall survival rate in patients with de novo stage IV breast cancer.

Methods: At initial diagnosis patients were randomized 1:1 to LRS group or ST group. The surgery was a lumpectomy (L) or mastectomy (M) and sentinel lymph node biopsy (SLNB) ± axillary lymph node dissection (ALND). After surgery all patients received systemic treatment + endocrine treatment (ET) and Trastuzumab based on pathology results. The demographic, pathologic, and clinical characteristics of the patients were recorded.

Results:274 patients were accrued; 138 in the LRS group and 136 in the ST group. The groups were comparable regarding age, BMI, HER2 neu, tumor type and size, histologic grade, and bone and visceral metastasis (all p&gt;0.05). In the LRS group 36 patients (26%) had L+ALND, 92 patients (67%) had M+ALND and 10 patients (7%) had M+SLNB, respectively.

The patients and tumor characteristicsPatients and Tumors Characteristics and Surgical TreatmentSurgerySystemic TherapyP ValueAge (mean /year±SD)51.8 ±12.651.5±13.6NSMedian follow-up (25%,75%)41.0 (24,54)37 (18,49) Tumor Size (%)   T18.7 (12) NST252.2 (72) NST321.7 (30) NST417.4 (24) NSHistologic Grade (%)   I4.4 (6)9.6 (10)NSII39.9 (55)31.7 (33)NSIII55.8 (77)58.9 (61)NS    Surgical Treatment   Lumpectomy+ ALND26 (36)--M + SLNB7 (10)--M + ALND67 (92)---SLNB17 (23)--ALND92.8 (128)--pN+89.1 (123)--30-day mortality1.4 (2)1.5 (2)0.98SLNB-Sentinel Lymph Node Biopsy; ALND-Axillary Lymph Node Dissection; M-Mastectomy

The axillary positivity rate was 89.1%. There were 76 (55%) deaths in the LRS group and 101 (74%) in the ST group during the median 40 (20-51) month follow-up. Overall survival (OS) was 34% higher in the LRS group compared to the ST group (HR: 0.66, 95%CI 0.49-0.88: p = 0.005).

Overall survival rate was higher in LN (+) (p=0.01), tumor size&lt;5cm (p&lt;0.0001), and high histologic grade (HG III, p&lt;0.008) patients who underwent axillary surgery than ST group ; OS rate was with a marginal significant level in patients without axillary involvement (pN0) in the LRS group compared with ST group (p=0.05).

Conclusion: In this subgroup analysis, we observed that patients with high grade tumor, without skin or chest wall involvement and positive axilla who underwent surgery for primary breast tumor and axilla had better overall survival than ST in de novo stage IV breast. These results can be considered in clinical research design for stratification.

Citation Format: Ozmen V, Ozbas S, Karanlik H, Muslumanoglu M, Igci A, Canturk Z, Utkan NZ, Ozaslan C, Evrensel T, Uras C, Aksaz E, Soyder A, Ugurlu UM, Col C, Cabioglu N, Bozkurt B, Sezgin E, Dagoglu T, Uzunkoy A, Dulger M, Koksal N, Cengiz O, Gulluoglu B, Unal B, Atalay C, Yildirim E, Erdem E, Salimoglu S, Sezer A, Koyuncu A, Gurleyik G, Alagol H, Ulufi N, Berberoglu U, Soran A. The importance of loco-regional tumor burden and surgery on survival in patients with de novo stage IV breast cancer; post-hoc analyses of protocol MF07-01 [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-16-01.

Abstract P6-07-24: miR-19b-3p and miR-4687-5p as novel circulating miRNAs as potential prognostic biomarkers in breast cancer

Background

Circulating microRNAs (miRNAs) as regulators of gene expression have recntly been promising suitable potential biomarkers due to their stability and ease of detection in blood. In this study, we aimed to determine the plasma expression levels of 372 different miRNAs in patients with invasive ductal breast cancer (IDC).

Methods

The expression levels of 372 circulating miRNAs in plasma samples of 20 patients with operable stage 1-III IDC and 10 healthy controls were determined using RT-PCR arrays. Mean ages of patients and healthy controls were 45.9+/-8.8) and 45.4+/- 5) respectively. Of 20 breast tumors, 12 were luminal breast cancer, whereas 8 were non-luminal as pure HER2-neu or triple negative breast cancer. RNA was isolated using miRNeasy Serum/Plasma Kit (Qiagen, Hilden, Germany, Cat. No: 217004). cDNA synthesis was performed according to manufacturer's instructions with miScript II RT Kit (Qiagen,Hilden, Germany, Cat. No: 218161). Serum/Plasma 384 HC PCR arrays with miScript SYBR Green PCR Kit (Qiagen, Hilden, Germany, Cat. No:218076) were used RT-PCR analysis. These assays included 372 miRNAs in additon to housekeeping genes and reaction controls. All reactions were performed in triplicates. Ct values were analyzed via an online software developed by Sabiosciences. P values were calculated using Student's t-test and p values lower than 0.05 were considered significant.

Results

Among 372 miRNAs, 19 were found to be deregulated in plasma samples of patients with IDC. 8 miRNAs were upregulated, and the other 11 were downregulated.

Upregulated and Downregulated Circulating miRNAs in Patients with Invasive Ductal CarcinomaUpregulated miRNAsFold regulationp valueDownregulated miRNAsFold Regulationp valuemiR-29a-3p2.0240.032miR-19b-1-5p-2.3750.048miR-101-3p2.4000.040miR-4732-5p-2.0910.015miR-542-3p2.2910.042miR-4687-5p-4.6230.005miR-199b-3p2.0190.020miR-3135b-2.7920.0005miR-98-5p2.4830.003miR-4770-2.4150.0103miR-424-5p3.0550.034miR-4301-2.6680.007miR-374c-5p2.1100.049miR-1247-5p-2.8130.0003miR-19b-3p3.7590.048miR-1287-5p-2.2020.0007   miR-197-3p-4.090.023   miR-126-5p-2.0520.029   miR-671-3p-2.5350.014Table 1

miR-19b-3p was the most upregulated miRNA with a fold change of 3.759 (95%CI:1.83- 5.68, p=.048) while miR-4687-5p was the most downregulated with a fold change of 0.216 (95%CI:0.00001-0.43, p=.005).

Conclusion

Our findings indicate that these 19 deregulated circulating miRNAs might be promising biomarker candidates for detection of IDC. The two most deregulated miRNAs were miR-19b-3p and miR-4687-5p. miR19b-3p belongs to a cluster of miRNAs which has been shown to function as oncogenes resulting in the downregulation of tissue factor expression in breast cancer cells. Further validation studies are ongoing in order to determine their clinicopathological prognostic value in breast cancer.

Citation Format: Tiryakioglu NO, Cabioglu N, Coskunpinar E, Tukenmez M, Ozturk D, Ozkurt E, Igci A, Pence S, Muslumanoglu M. miR-19b-3p and miR-4687-5p as novel circulating miRNAs as potential prognostic biomarkers in breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-07-24.

Metaplastic Breast Carcinoma Versus Triple-Negative Breast Cancer: Survival and Response to Treatment

Metaplastic breast carcinoma (MBC) differs from classic invasive ductal carcinomas regarding incidence, pathogenesis, and prognosis. The purpose of this study was to compare patients with MBC with clinicopathologic and treatment-matched patients with triple-negative breast carcinoma (TNBC) in terms of response to treatment, progression, and survival.Fifty-four patients with MBC and 51 with TNBC, who were treated at Istanbul University, Institute of Oncology, between 1993 and 2014, were included in the study. After correctly matching the patients with 1 of the 2 groups, they were compared to determine differences in response to treatment, disease progression, clinical course, and survival.At a median follow-up of 28 months, 18 patients (17.1%) died and 27 (25.5%) had disease progression. Metaplastic histology was significantly correlated with worse 3-year progression-free survival (PFS) (51 ± 9% vs. 82 ± 6%, P = 0.013) and overall survival (OS) (68 ± 8% vs. 94 ± 4%, P = 0.009) compared with TNBC histology. Patients who received taxane-based chemotherapy (CT) regimens or adjuvant radiotherapy had significantly better PFS (P = 0.002 and P < 0.001) and OS (P < 0.001 and P < 0.001) compared with others. In the multivariate analysis, MBC (hazard ratio [HR]: 0.09, P < 0.001), presence of neoadjuvant chemotherapy (NACT) (HR: 12.8, P = 0.05), and metastasis development at any time during the clinical course (HR: 38.7, P < 0.001) were significant factors that decreased PFS, whereas metastasis development was the only independent prognostic factor of OS (HR: 23.8, P = 0.009).MBC is significantly correlated with worse PFS and OS compared with TNBC. Patients with MBC are resistant to conventional CT agents, and more efficient treatment regimens are required.

The use of Ligasure vessel sealing system in axillary dissection; effect on seroma formation

BACKGROUND

Seroma formation is the most frequent postoperative complication after axillary dissection for breast surgery with an incidence of 10 - 50 %. This prospective clinical randomized study was carried out to evaluate the Ligasure vessel sealing system and its effect on seromaformation and other complications for axillary dissection.

METHODS

Between January 2006 and November 2007, the patients with histopathological diagnosis of breast cancer were analysed prospectively. The patients with positive sentinel lymph node biopsy or clinical axillary involvement were included in the study, and the patients who underwent neoadjuvant therapy or using anticoagulants have been excluded from the study. Patients were divided into two study groups.Axillary dissection was performed in the first group by LigaSure and in the second group by linking and electrocautery.

RESULTS

There were a total of thirty three patients with a mean age of 51.4 +- 13.7. In group one, mean age of patients was 54.1 +- 13.2 and 48.68 +- 14.1 in group two. There was no significant statistical difference between the groups regarding age, body mass index, excised tissue weight,tumour size and number of excised lymph nodes. The use of Ligasure reduced drainage amount and duration of drain till removal, but increased operative time.

CONCLUSION

There were no significant differences between study groups regarding the complications. LigaSure electrothermal bipolar vessel sealing system can be safely used in axillary dissection as an alternative to traditional methods.

Videoendoscopic single-port nipple-sparing mastectomy and immediate reconstruction

PURPOSE

Single-incision videoendoscopic surgery has recently become popular as a result of the ongoing search for less invasive procedures. The aim of this study was to evaluate the safety and efficacy of endoscopic single-port nipple-sparing mastectomy, axillary lymphadenectomy, and immediate reconstruction in patients with breast cancer.

PATIENTS AND METHODS

From May 14, 2012 through January 23, 2013, 10 patients underwent videoendoscopic single-port nipple-sparing mastectomy and axillary dissection via a single, limited incision and immediate prosthetic reconstruction. Patient charts were reviewed, and demographic data, operative time, complications and pathology results were analyzed.

RESULTS

In all patients, videoendoscopic surgery was performed successfully. Of 10 patients, 7 were diagnosed as having invasive ductal carcinoma, 2 had a ductal carcinoma in situ, and 1 underwent bilateral prophylactic mastectomy. The weight of the resected gland was 300-650 g, with a mean of 420 g. There were no operative complications, and the mean operative time was 250 minutes (range, 160-330 minutes). One-stage reconstruction with implants was performed on 4 patients, whereas expanders were placed in the remaining 6. Surgical margins of all cases were pathologically negative, and there were no recurrences observed during the early follow-up period.

CONCLUSIONS

Videoendoscopic single-port nipple-sparing mastectomy is technically feasible even in larger breasts, enabling immediate reconstruction with good cosmetic outcomes. However, further studies with larger clinical series and long-term follow-up are required to compare the safety and efficacy of the technique with those of the standard nipple-sparing mastectomy.

Abstract P4-07-08: The predictive and prognostic role of tumoral miRNA expression levels in patients with breast cancer (BC) treated with neoadjuvant chemotherapy (NAC)

Over the last decade, miRNA's have gained considerable interest due to the accumulating evidence regarding their relevant regulatory functions on cancer initiation, proliferation and progression. Furthermore, there are data showing that miRNA's can have a predictive role in response to NAC. The aim of this study is to evaluate the association between miRNA expression profile and response to NAC in patients with BC. 21 patients who received NAC consisting of 4 cycles of antracycline and cyclophosphamide (EC), followed by 4 cycles of docetaxel (T) were included in this study. Tumor core biopsies and blood specimens were collected before initiation, before the 5th cycle and after the completion of NAC for pathologic evaluation, miRNA expression and circulating correlative miRNA levels. The miRNA profile consisted of 9 miRNA's that were previously shown to be related to anthracycline and taxane resistance, as well as those associated with various intracellular functions. Associations with miRNA expression and clinical and pathologic variables, including response were evaluated by the Spearmann Correlation test. Response assessment was carried out every couple of cycles by physical examination, and radiologic evaluation after 4 and 8 cycles, respectively. Clinical response to EC was complete regression in 4.76% (n:1), PR in 66.7% (n:14), minimal response in 23.8% (n:5); and progression in 4.76% (n:1); all patients responded to docetaxel with 1 having CR and 20 PR. Pathologic response evaluation revealed CR in 7 patients (33.3%), good PR (defined as more than 50% regression in the viable tumor cells) in 8 (38.1%) and minimal PR in 6 (28.6%). Baseline levels of miRNA expression before initiation of NAC from the lowest to the highest level were as follows: miR10b (mean relative value (MRV): 0.24), miR-200c, miR34a, miR-11, let7a, miR-200c, miR-21, miR-195 and miR-221 (MRV: 132.5). Although each miRNA tested were in positive correlation with each other (p&lt;0.05), there was no association with any miRNA with known clinic-pathologic variables, such as ER, PR, Her-2/neu or Ki67 levels. All miRNA's showed higher levels in patients presenting with stage 2 disease compared to those with stage 3 disease, which was marginally significant for miR-155 and miR-21 (p:0.05). After 4 cycles of EC miR-21 and miR-195 expression decreased significantly (mean decrease 500 times the initial level) (p&lt;0.05), which was more evident in patients with earlier stage at presentation (stage 2 versus stage 3 disease (p:0.03)). There were no significant correlations seen with any miRNA and response to taxane-based NAC, since all patients showed a response. Furthermore, there was no correlation between pCR and the miRNA's tested. Nevertheless, there was a trend for higher pre-treatment miR-34 levels predictive for a good clinical response to EC, which was defined as more than 50% regression in the largest tumor diameter (p:0.07). In this preliminary study, we have shown that a substantial decrease in miR-155, -21,and -195 expressions after 4 cycles of EC may be associated with clinical response to anthracycline-based NAC. Furthermore, a higher miR-34 expression may predict for athracycline responsiveness.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-07-08.

Male breast cancer: a retrospective study of 15 years

PURPOSE

To retrospectively evaluate the 15-year experience with breast cancer in males at a single institution.

METHODS

The data from 25 male patients who had undergone surgery for breast cancer at a single center were retrospectively analysed. Their medical records were studied for clinical characteristics, therapeutic modalities used and factors associated with disease free (DFS) and overall survival (OS), like local recurrence/distant metastasis.

RESULTS

The median patient age was 67 years (range 38-83). The most frequent presenting symptom was a palpable lump. Eighteen (72%) patients underwent modified radical mastectomy (MRM), while sentinel lymph node biopsy (SLNB) was performed in 14 (56%) cases. Of 25 patients, 21 (84%) underwent axillary lymph node dissection (ALND) and 15 (71.4%) of them had pathological axillary lymph node involvement. Two of 25 (8%) patients with bone and liver metastases underwent toilet mastectomy due to breast ulceration. Estrogen receptor (ER) was positive in 15 (60%) patients, while progesterone receptor (PR) and C-erbB2 (HER-2) were positive in 10 (40%) and 2 (8%) patients, respectively. Ten patients (40%) had both ER(+) and PR(+). The median follow-up period was 19 months (range 3-102). Local recurrence developed in one (4%) patient and distant metastasis in 4 (16%). Five-year OS and DFS were 53 and 49%, respectively. In univariate and multivariate analysis, pathological tumor size (<2 vs. >2 cm), pathological lymph node involvement and preoperative skin involvement over the breast were not associated with breast recurrence. Only in univariate analysis local recurrence/distant metastasis were associated with poor OS.

CONCLUSION

Large cooperative studies are needed using strict clinical and laboratory criteria to advance the understanding of this disease and to identify the most effective treatment approaches.

Trastuzumab use and survival in HER2 (+) nonmetastatic breast cancer among Turkish women

56

Background: HER2 overexpression observed in 10-25% of breast cancers is associated with rapid proliferation. HER2-targeted trastuzumab has been used in metastatic breast cancer, and since 2004 in early breast cancer. However, trastuzumab therapy is expensive and long lasting resulting sometimes in cardiac side effects. In this study we tried to find out whether there was a subgroup of early breast cancer patients trastuzumab could be omitted.

Methods: Records of patients treated for HER2-positive breast cancer in Istanbul Medical School between Jan 2000 and Sept 2009 were retrospectively evaluated. Disease-free survival (DFS) and overall survival (OS) were calculated either from follow-ups, or by calling. Kaplan meier and LogRank tests have been used for comparison (P<0.05, 95% CI).

Results: Follow up period was 32.2±14.9mo for trastuzumab group (TG, n:87) compared to 47.4±20.8mo for non-trastuzumab group (NTG, n:63) (P=0.0001). Groups were similar for age, menopausal status, size (T), histological grade and type, location, hormone responsiveness, presence of lymphovascular invasion, surgery, and use of local/systemic/hormonal therapy. NTG had more N0 cases (44.4% vs. 12.6%, P=0.0001), breast related deaths (15.9% vs. 5.7%, P=.042) and systemic metastases (27% vs. 13.8%, P=.043). Number of local recurrences was similar. Mean DFS and OS were significantly less in TG (P<0.0001). However differences between DFS and OS of groups were not significant despite a considerable increase for both in TG at fifth year (P=0.147, P=0.450). No difference in DFS and OS between TG and NTG was observed when patients who had chemotherapy and/or radiotherapy and/or hormonotherapy were compared to those who did not. OS was not different between TG and NTG for T1, T2, and T3 tumors and for patients ≤35y. But in N2 and N3 tumors, use of trastuzumab increased OS significantly (P=0.007).

Conclusions: Both number of events and systemic relapses were less in TG but we could not find a significant difference in DFS and OS between TG and NTG in Turkish nonmetastatic cancers. Prolonged follow up might be necessary to search for the subgroup who would not benefit, if any, as an incremental benefit in both DFS and OS was observed with trastuzumab use at fifth year.

Breast conserving surgery in patients with multifocal/multicentric breast cancer

PURPOSE

To retrospectively evaluate the outcome of patients with multifocal (MF) and multicentric (MC) breast cancer treated with conservative surgery.

METHODS

We evaluated 59 patients who had undergone breast conserving surgery (BCS) for MF/MC cancer between 1998-2008. We used sentinel lymph node (SLN) biopsy for all 59 patients and we performed axillary lymph node dissection in those with positive SLN. Local control, overall survival (OS), disease-free survival (DFS) and identification of predictive factors for recurrence were evaluated.

RESULTS

Twenty patients with modified radical mastectomy because of persistent positive margins were excluded from the study. Evaluated were 55 patients with MF (93.2%) and 4 (6.8%) with MC disease. Thirty-four patients (57.6%) had 2, 20 patients (33.9%) had 3 and 5 (8.5%) had 4 or more tumor foci. Median follow up time was 20 months (range 2- 97). The projected 5- and 8-year OS were 95% and 89% respectively, and DFS 92.3%. At multivariate analysis, overexpression of human epidermal growth factor receptor 2 (HER-2) was associated with a higher ipsilateral breast cancer recurrence. Menopausal status, MF/MC disease, number of tumor foci (2 vs. ≥3), histological grade, extracapsular extension (ECE), lymphovascular invasion (LVI), and hormone receptor status were not associated with ipsilateral breast cancer recurrence.

CONCLUSION

Our study demonstrates that in selected patients with MF/MC breast cancer, wide conservative surgery is a safe therapy.

Clinical importance of micrometastasis in sentinel lymph nodes

INTRODUCTION

We evaluated the incidence of micrometastasis and nonsentinel lymph node metastasis as well as local and axillary recurrence rates after level I-II axillary lymph node dissection.

MATERIALS AND METHODS

Patients (n=760) with early-stage breast cancer underwent sentinel lymph node biopsy, and 45 patients (6.0%) with micrometastasis (0.2-2.0mm) were included in this study. Data concerning tumor, patients' characteristics and adjuvant treatments were recorded.

RESULTS

The median age was 46 (26-67) years, median breast tumor size was 20 (1-50) mm, and median number of excised sentinel lymph nodes were 2 (1-5). All patients with micrometastasis underwent further level I-II axillary lymph node dissection. Eleven of 45 (24.4%) patients with micrometastasis in their sentinel lymph node biopsy had nonsentinel lymph node metastasis after an axillary lymph node dissection. There was no factor related to nonsentinel lymph node metastasis. Stage migration occurred in 4 of 45 patients (8.8%) due to the detection of micrometastases or macrometastases in nonsentinel lymph nodes.

DISCUSSION

The classical treatment after detection of micrometastasis in sentinel lymph nodes is further axillary dissection. However, nonrandomized, nonprospective studies with 4-5 years follow up showed 0.6% axillary recurrence without further axillary lymph node dissection, although we still need the results of randomized controlled studies.

Axillary sentinel node biopsy after neoadjuvant chemotherapy

INTRODUCTION

The role of sentinel lymph node biopsy (SLNB) in patients with locally advanced breast cancer (LABC) with potentially sterilized axillary lymph nodes after neoadjuvant chemotherapy (NAC) remains unclear.

PATIENTS AND METHODS

Between 2002 and 2008, SLNB with both blue-dye and radioisotope injection was performed in 77 patients with LABC whose cytopathologically confirmed positive axillary node(s) became clinically negative after NAC. Factors associated with SLN identification and false-negative rates, presence of non-sentinel lymph node (non-SLN) metastasis were analyzed retrospectively.

RESULTS

SLNB was successful in 92% of the patients. Axillary status was predicted with 90% accuracy and a false-negative rate of 13.7%. Patients with residual tumor size >2 cm had a decreased SLN identification rate (p=0.002). Axillary nodal status before NAC (N2 versus N1) was associated with higher false-negative rates (p=0.04). Positive non-SLN(s) were more frequent in patients with multifocal/multicentric tumors (versus unifocal; p=0.003) and positive lymphovascular invasion (versus negative; p=0.0001). SLN(s) positive patients with pathologic tumor size >2 cm (versus <or=2 cm; p=0.004), positive extra-sentinel lymph node extension (versus negative; p=0.002) were more likely to have metastatic non-SLN(s).

CONCLUSIONS

SLNB has a high identification rate and modest false-negative rate in LABC patients who became clinically axillary node negative after NAC. Residual tumor size and nodal status before NAC affect SLNB accuracy. Additional involvement of non-SLN(s) increases with the presence of multifocal/multicentric tumors, lymphovascular invasion, residual tumor size >2 cm, and extra-sentinel node extension.

Complications of local/regional treatment of breast cancer and quality of life

e11597

The aim of this prospective clinical study was to evaluate early and late complications of different surgical procedures, and compare conservative surgical treatments (breast conserving surgery, sentinel lymph node biopsy) to more radical ones (mastectomy, axillary lymph node dissection), and find factors that were related to these complications. 218 early stage breast cancer patients (stage I and II) were enrolled in this study. Physical complications (restrictions in shoulder motions, shoulder functional capacity, pain, lymphedema and sensory loss), psychological complications and the factors related to these complications were studied in patients after breast cancer surgery and/or radiotherapy at first week, at 9th-12th months and at mean follow up time of 34 months. Lymphedema rates after surgery were 14.7 %, 24.8% and 17.0% at first week, 9th-12th months, and long term respectively. In early postoperative period, pain and functional capacity of the effected shoulder were worse than preoperatively measured values and all axis of motion of shoulder joint were effected significantly. On the other hand, at 9th-12th months, only internal flexion was still affected. At the long term period, all axis of motion of shoulder joint, pain and functional capacity were in normal range as before treatment. The factors related to lymphedema were axillary lymph node dissection (p=0.002), radiation therapy to axillae (p<0.001). The patients who had both axillary lymph node dissection and axillary radiotherapy had more lymphedema than the patients who only had axillary lymph node dissection or sentinel lymph node biopsy (p=0.004). The factors related to postoperative depression at early period were cigarette smoking (p=0.008), axillary lymph node dissection (p=0.045) and arm lymphedema (p=0.005). At long term period they were axillary lymph node dissection (p=0.021), mastectomy (p=0.036), drain usage (p=0.028) and sensory loss (p=0.027). The patients who had sentinel lymph node biopsy, axillary dissection without axillary radiotherapy had better quality of life. The patients with cigarette smoking, axillary lymph node dissection, mastectomy, drain, lymphedema and sensory loss had increased incidence of depression than others, these results were statistically significant.

No significant financial relationships to disclose.

Predictive factor for residual tumor after lumpectomy for close margins

e11538

Background: It is critical to obtain clear margins to minimize local recurrence after breast conserving surgery(BCS). When re-excisions are performed, there is often no residual disease in the new specimen, calling into question the need for re-excision(s) or mastectomy. The aim of the present study was to identify factors predicting a histologically positive re-excision specimen. Methods: Our prospective breast cancer database was queried for all invasive breast cancer patients who underwent a re-excision lumpectomy for either close or positive margins after an attempt at BCS. Close margins are defined as ≤ 2 mm for invasive carcinoma and presence of ductal carcinoma in situ(DCIS). Clinicopathologic features were correlated with the presence of residual disease in the re-excision specimen. Results: Between February 1997 and August 2008, 2054 patients with early breast cancer underwent surgical treatment in our breast unit. 939(45.7%) of them had BCS. In 543 patients(26.4%), re-excision required due to close margins on the permanent section analysis of their initial surgical specimens. 186 patients(34.3%) had previous excisional biopsy in other clinics. Median age of 543 patients was 50 years. In 290 patients(53.4%), mastectomy was performed due to positive surgical margin or poor cosmetic results. There were no residual tumors in re-excision(65.6 %) or mastectomy(42.4%) specimens of patients. The factors associated with tumor positive re-excision specimen were, age ≤50 years(p=0.044), lymphovascular invasion (p=0.029), multifocality(p<0.001), tumor size >2cm(p=0.008), presence of DCIS(p=0.018), focal margin positivity(p<0.001), DCIS at resection margin(p=0.008) and node positivity (p<0.001). Conclusions: Most of our patients with early breast cancer had unnecessary re-excisions or mastectomy to obtain clear surgical margins. In subset group of patients, re-excision or mastectomy may not be required.

No significant financial relationships to disclose.

Metastatic lymph node ratio is an independent prognostic factor in gastric cancer

BACKGROUND/AIMS

The metastatic status of the regional lymph node is the most significant prognostic factor for gastric cancer. However, diverse prognoses are evident even among the same N classifications of the current tumor-node-metastasis system. The aim of this study is to evaluate the prognostic significance of the ratio of metastatic to examined lymph nodes (N ratio) for identifying a high-risk subgroup of patients with gastric cancer.

METHODOLOGY

The postoperative survival of 264 consecutive patients with operable gastric cancer was analyzed with regard to its N ratio and current N classification. Survival was determined by the Kaplan-Meier method and differences were assessed by the log-rank test. Multivariate analysis was performed using the Cox proportional hazards model in forward stepwise regression.

RESULTS

The lymph node ratio was classified as follows N ratio 1, 1 to 10, N ratio 2, 11 to 25; and N ratio 3, >25. The 5-year survival rates stratified by N ratio were N ratio 1, 81%; N ratio 2, 49%; N ratio 3, 25%. The rates of survival were significantly different according to the N ratio in pN1 and pN2 classification of the UICC/TNM classification (p<0.05). Cox regression analysis revealed that N ratio was sensitive prognostic factor in these surgically treated patients, which were also significantly correlated with extent of lymph node dissection and pathologic tumor stage (p<0.05).

CONCLUSIONS

N ratio can be recommended as an applicable parameter for lymph node involvement of gastric cancer. It is a more effective and precise indicator for prognostic stratification of patients with lymph node positive gastric cancer than the current N classification of the tumor-node-metastasis system.