Developing Cardio-Oncology Programs in the New Era: Beyond Ventricular Dysfunction Due to Cancer Treatments

Cardiovascular disease is a common problem in cancer patients that is becoming more widely recognized. This may be a consequence of prior cardiovascular risk factors but could also be secondary to the anticancer treatments. With the goal of offering a multidisciplinary approach to guaranteeing optimal cancer therapy and the early detection of related cardiac diseases, and in light of the recent ESC Cardio-Oncology Guideline recommendations, we developed a Cardio-Oncology unit devoted to the prevention and management of these specific complications. This document brings together important aspects to consider for the development and organization of a Cardio-Oncology program through our own experience and the current evidence.

Abstract P1-08-26: Morphologic characterization of tumor-infiltrating lymphocytes and its relation with pathological response in a series of breast cancer patients treated with primary chemotherapy

Introduction: Tumor-Infiltrating Lymphocytes (TILS) is a well-known predictor of response to primary chemotherapy1,2 and a prognostic factor for improved survival in different breast cancer subtypes3. We present data on the association of the level of TILs and morphologic characteristics of such infiltrate with pCR. Material and methods: A series of 477 breast cancer patients (479 tumors) treated with primary chemotherapy at Catalan Institut of Oncolgy - H.U. Bellvitge between January 2009 and December 2016. Chemotherapy consisted on anthracyclines and taxanes (plus trastuzumab if Her-2 positive disease). Levels of percentage of TILs using hematoxylin-eosin-stained sections of diagnostic core-needle biopsy were evaluated according to international guidelines in a prospectively defined retrospective analysis. Characterization of TILS consisted on identification of plasma cells, intraepithelial infiltrate vs stromal infiltrate and homogeneous vs heterogeneous infiltrate. A sub-classification using levels of TILS and heterogeneity was done for statistical purposes. Levels of TILS and their morphological characteristics were examined for their associations with pCR adjusted for predictive clinic-pathological factors, by univariate and multivariate logistic regression, statistical significance set at 0.05. A ROC curve was performed to look for a cut-point of TILs to predict PCR. Results: The mean value of TILs was 23.79% (SD, 24%). TILs were significantly higher in ductal carcinomas (39.1% vs 0%, p=0.007), grade 3 (55.2 vs 17.7%p<0.001), ki 67 >30 (48.8% vs 24.5%, p<0.001), HER2 (56.6%) and triple negative tumors (TNBC)(56.6%) vs luminal (20%), p<0.001). The level of TILS was set in 20% to predict pCR by a ROC curve (S=62.3% E=71%). Characterization of TILs found plasma cells in 41.1% of the samples, intraepithelial infiltrate in 11.2% and homogeneous infiltrate in 60.1%. Homogeneously high infiltrate was found in 20% of the samples. In the univariate analysis pCR was higher in samples with TILs > 20% (15.2% vs 41.5%, OR: 3.96 [95%CI, 2.57-6.10]; P < 0.001); plasma cells (OR 6.61 [95%CI, 1.51-28.8]; P=0.01), intraepithelial TILS (OR: 10.34 [95%CI, 2.22-48.01]; P =0.003), homogeneous high infiltrate (OR: 13.6 [95%CI, 3.04-60.77]; P =0.001). In luminal tumors, TILs over 20% predicted pCR (OR 12.3 [95%CI, 4.0-37.7]; P < 0.001) as well as in TNBC (OR 4.32 [95%CI, 1.77-10.53]; P=0 .001) but not in those cases with HER2 positive tumors (luminalB HER2 + HER2) (OR 1.65 [95%CI, 0.88-3.07]; P=0.118). In the multivariate analyses, levels of TILs > 20% were associated with higher pCR rates (adjusted odds ratio, 2.44 [95%CI, 1.48-4.01]; P < .001). Conclusions: The presence of TILs over 20% at diagnosis is an independent, positive, predictive marker of pCR in early breast cancer treated with neoadjuvant chemotherapy. Interestingly, the predictive information added by TILs >20% was higher in luminal and triple negative tumors compared to HER2 positive cases. Careful morphological characterization of TILS may add valuable predictive information and can be done in current pathologic laboratories with a well-trained breast cancer pathologist. References: 1.J Clin Oncol 2009; 28:105-113. doi: 10.1200/JCO.2009.23.73702.JAMA Oncol. 2015;1(4):448-454. doi:10.1001/jamaoncol.2015.08303.Lancet Oncol 2018: 19: 40-50 http://dx.doi.org/10.1016/S1470-2045(17)30904-X.

N%Age years (mean, sd)Grade*I326.7II19540.7III15152.6Ki 67≤3020442.6>3027557.4Molecular subtype*Luminal A469.6Luminal B HER2 -14329.9Luminal B HER2+9219.2HER+ enriched7615.9Triple negative12225.5Pathologic responseNon-pCR35874.7pCR12125.3

Citation Format: Catalina Falo, Juan Azcarate, Ana Petit, Andrea Vethencourt, Sergi Fernandez Gonzalez, Amparo Garcia-Tejedor, Silvia Vazquez, Hector Perez, Maria Laplana, Charo Taco, Esther Guerra, Anna Guma, Raul Ortega, Agostina Stradella, Sabela Recalde, Adela Fernandez-Ortega, Rafael Villanueva, F Javier Perez, M Jesus Pla, Miriam Campos, Diana Perez, Eulalia Fernandez-Montoliu, Veronica Obadia, Monica Cejuela, Miguel Gil-Gil, Sonia Pernas, Mar Varela, Teresa Soler-Monzo. Morphologic characterization of tumor-infiltrating lymphocytes and its relation with pathological response in a series of breast cancer patients treated with primary chemotherapy [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 P1-08-26.

PAM50 Subtypes in Baseline and Residual Tumors Following Neoadjuvant Trastuzumab-Based Chemotherapy in HER2-Positive Breast Cancer: A Consecutive-Series From a Single Institution

Introduction: HER2-enriched subtype has been associated with higher response to neoadjuvant anti-HER2-based therapy across various clinical trials. However, limited data exist in real-world practice and regarding residual disease. Here, we evaluate the association of HER2-enriched with pathological response (pCR) and gene expression changes in pre- and post-treatment paired samples in HER2-positive breast cancer patients treated outside of a clinical trial.

Methods: We evaluated clinical-pathological data from a consecutive series of 150 patients with stage II-IIIC HER2-positive breast cancer treated from August 2004 to December 2012 with trastuzumab-based neoadjuvant chemotherapy. Expression of 105 breast cancer-related genes, including the PAM50 genes, was determined in available pre-and post-treatment formalin-fixed paraffin-embedded tumor samples using the nCounter platform. Intrinsic molecular subtypes were determined using the research-based PAM50 predictor. Association of genomic variables with total pCR was performed.

Results: The pCR rate was 53.3%, with higher pCR among hormonal receptor (HR)-negative tumors (70 vs. 39%; P < 0.001). A total of 89 baseline and 28 residual tumors were profiled, including pre- and post-treatment paired samples from 26 patients not achieving a pCR. HER2-enriched was the predominant baseline subtype not only in the overall and HR-negative cohorts (64 and 75%, respectively), but also in the HR-positive cohort (55%). HER2-enriched was associated with higher pCR rates compared to non-HER2-enriched subtypes (65 vs. 31%; OR = 4.07, 95% CI 1.65–10.61, P < 0.002) and this association was independent of HR status. In pre- and post-treatment paired samples from patients not achieving a pCR, a lower proportion of HER2-enriched and twice the number of luminal tumors were observed at baseline, and luminal A was the most frequent subtype in residual tumors. Interestingly, most (81.8%) HER2-enriched tumors changed to non-HER2-enriched, whereas most luminal A samples maintained the same subtype in residual tumors.

Conclusions: Outside of a clinical trial, PAM50 HER2-enriched subtype predicts pCR beyond HR status following trastuzumab-based chemotherapy in HER2-positive disease. The clinical value of intrinsic molecular subtype in residual disease warrants further investigation.

Abstract P2-09-11: PAM50 intrinsic subtyping as a predictor of pathological complete response to neoadjuvant trastuzumab-based chemotherapy in early HER2-positive breast cancer

Background: HER2-positive breast cancer (BC) is a heterogeneous disease from a clinical and biological perspective. Intrinsic subtype defined by gene expression has an important role in determining response to treatment, as seen in several neoadjuvant trials (e.g. CALGB40601, CherLOB, NeoALTTO and PAMELA). However, limited data exist in an off-trial setting. The objective of this study was to evaluate the association of intrinsic subtypes with pathological completed response (pCR) and survival outcomes of a series of HER2-positive patients (pts) homogeneously treated with trastuzumab-based primary chemotherapy (PC) in a single comprehensive cancer center.

Methods: Clinical-pathological data were evaluated in a series of 150 consecutive stage II-IIIC (T4d included) HER2-positive BC pts treated in ICO-Hospitalet (Spain) from August-2009 to December-2012 with weekly paclitaxel x12 followed by FEC/3w x 4 and concurrent trastuzumab for a total of 24w. HER2-positivity was considered according to ASCO-CAP 2007 guidelines. pCR was defined as ypT0/isypN0. The expression of 105 BC-related genes, including the PAM50 genes, was determined in baseline and residual formalin-fixed paraffin-embedded tumor samples using the nCounter platform. Intrinsic subtypes were determined by the research-based PAM50 gene expression predictor. Association of variables with pCR or disease-free survival (DFS) was evaluated using logistic regression analyses and cox proportional hazard models.All statistical tests were two-sided and considered significant when p≤0.05.

Results: Most pts had T2 (64%) and T4 (20%) tumors and clinically node-positive disease (77%). 53% had hormonal receptor (HR)+ disease. 84 of the 150pts (56%) achieved a pCR; HR-neg was associated with higher pCR rates (72.5%vs 42% in HR+ P&lt;0.001). 90 of the 150 (60%) baseline samples were evaluated. Baseline subtype distribution: HER2-enriched (HER2-E) 63%, Luminal A 11%, Basal-like 8.9%, Normal-like 8.9% and Luminal B 7.8%. Although HER2-E predominated in HR-neg tumors (74%), 53% of HR+ tumors were HER2-E. pCR rates varied according to intrinsic subtype (P&lt;0.001). HER2-E tumors were associated with higher pCR rates compared to non-HER2-E (68.4% vs 33.3%, P&lt;0.001) regardless HR-status. Five of the 8 PAM50 signatures (HER2E, ROR-S, ROR-P, Basal-like and Proliferation score) were associated with pCR, whereas Luminal A was associated with no-pCR (P&lt;0.001). With a median follow-up of 6.6 years, HER2-E subtype was associated with a better DFS compared to non-HER2-E (5-year DFS 92.4% vs 75.9%; HR= 0.27; 95% CI 0.08-0.91; P=0.034). Finally, 28 of the 66 (42.4%) surgical specimens with residual disease were studied. Residual subtype distribution was: Normal-like (50.0%), Luminal A (32.1%), HER2-E (14.3%) and Luminal B (3.5%).

Conclusions: In this consecutive series of HER2-positive BCtreated homogeneously with neoadjuvant trastuzumab-based PC, all of the main intrinsic molecular subtypes were identified with a predominance of HER2-E. HER2-E was significantly associated with pCR and survival outcome. Distribution of the intrinsic subtypes in residual disease differed from untreated tumors.

Citation Format: Pernas S, Petit A, Climent F, Pare L, Perez-Martin J, Ventura L, Galvan P, Falo C, Morilla I, Fernandez-Ortega A, Stradella A, Pascual T, Gil-Gil M, Prat A. PAM50 intrinsic subtyping as a predictor of pathological complete response to neoadjuvant trastuzumab-based chemotherapy in early HER2-positive breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-09-11.