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Sigurjonsdottir G, De Marchi T, Ehinger A, Hartman J, Bosch A, Staaf J, Killander F, Niméus E. Comparison of SP142 and 22C3 PD-L1 assays in a population-based cohort of triple-negative breast cancer patients in the context of their clinically established scoring algorithms. Breast Cancer Res 2023; 25:123. [PMID: 37817263 PMCID: PMC10566164 DOI: 10.1186/s13058-023-01724-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 10/02/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Immunohistochemical (IHC) PD-L1 expression is commonly employed as predictive biomarker for checkpoint inhibitors in triple-negative breast cancer (TNBC). However, IHC evaluation methods are non-uniform and further studies are needed to optimize clinical utility. METHODS We compared the concordance, prognostic value and gene expression between PD-L1 IHC expression by SP142 immune cell (IC) score and 22C3 combined positive score (CPS; companion IHC diagnostic assays for atezolizumab and pembrolizumab, respectively) in a population-based cohort of 232 early-stage TNBC patients. RESULTS The expression rates of PD-L1 for SP142 IC ≥ 1%, 22C3 CPS ≥ 10, 22C3 CPS ≥ 1 and 22C3 IC ≥ 1% were 50.9%, 27.2%, 53.9% and 41.8%, respectively. The analytical concordance (kappa values) between SP142 IC+ and these three different 22C3 scorings were 73.7% (0.48, weak agreement), 81.5% (0.63) and 86.6% (0.73), respectively. The SP142 assay was better at identifying 22C3 positive tumors than the 22C3 assay was at detecting SP142 positive tumors. PD-L1 (CD274) gene expression (mRNA) showed a strong positive association with all two-categorical IHC scorings of the PD-L1 expression, irrespective of antibody and cut-off (Spearman Rho ranged from 0.59 to 0.62; all p-values < 0.001). PD-L1 IHC positivity and abundance of tumor infiltrating lymphocytes were of positive prognostic value in univariable regression analyses in patients treated with (neo)adjuvant chemotherapy, where it was strongest for 22C3 CPS ≥ 10 and distant relapse-free interval (HR = 0.18, p = 0.019). However, PD-L1 status was not independently prognostic when adjusting for abundance of tumor infiltrating lymphocytes in multivariable analyses. CONCLUSION Our findings support that the SP142 and 22C3 IHC assays, with their respective clinically applied scoring algorithms, are not analytically equivalent where they identify partially non-overlapping subpopulations of TNBC patients and cannot be substituted with one another regarding PD-L1 detection. Trial registration The Swedish Cancerome Analysis Network - Breast (SCAN-B) study, retrospectively registered 2nd Dec 2014 at ClinicalTrials.gov; ID NCT02306096.
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Affiliation(s)
- Gudbjörg Sigurjonsdottir
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Tommaso De Marchi
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Anna Ehinger
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Clinical Genetics, Pathology and Molecular Diagnostics, Laboratory Medicine, Region Skåne, Lund, Sweden
| | - Johan Hartman
- Department of Oncology and Pathology, Karolinska Institute and University Hospital, Stockholm, Sweden
| | - Ana Bosch
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Johan Staaf
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Division of Translational Cancer Research, Department of Laboratory Medicine, Lund University, Medicon Village, Lund, Sweden
| | - Fredrika Killander
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Emma Niméus
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
- Divison of Surgery, Department of Clinical Sciences Lund, Lund University, Sölvegatan 19 - BMC I12, 22184, Lund, Sweden.
- Department of Surgery, Skåne University Hospital, Malmö, Sweden.
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Egelberg M, De Marchi T, Pekar G, Tran L, Bendahl P, Tullberg AS, Holmberg E, Karlsson P, Farnebo M, Killander F, Nimeús E. Low levels of WRAP53 predict decreased efficacy of radiotherapy and are prognostic for local recurrence and death from breast cancer: a long-term follow-up of the SweBCG91RT randomized trial. Mol Oncol 2023; 17:2029-2040. [PMID: 36975842 PMCID: PMC10552889 DOI: 10.1002/1878-0261.13426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/08/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
Downregulation of the DNA repair protein WD40-encoding RNA antisense to p53 (WRAP53) has been associated with radiotherapy resistance and reduced cancer survival. The aim of this study was to evaluate WRAP53 protein and RNA levels as prognostic and predictive markers in the SweBCG91RT trial, in which breast cancer patients were randomized for postoperative radiotherapy. Using tissue microarray and microarray-based gene expression, 965 and 759 tumors were assessed for WRAP53 protein and RNA levels, respectively. Correlation with local recurrence and breast cancer-related death was assessed for prognosis, and the interaction between WRAP53 and radiotherapy in relation to local recurrence was assessed for radioresistance prediction. Tumors with low WRAP53 protein levels had a higher subhazard ratio (SHR) for local recurrence [1.76 (95% CI 1.10-2.79)] and breast cancer-related death [1.55 (1.02-2.38)]. Low WRAP53 RNA levels were associated with almost a three-fold decreased effect of radiotherapy in relation to ipsilateral breast tumor recurrence [IBTR; SHR 0.87 (95% CI 0.44-1.72)] compared with high RNA levels [0.33 (0.19-0.55)], with a significant interaction (P = 0.024). In conclusion, low WRAP53 protein is prognostic for local recurrence and breast cancer-related death. Low WRAP53 RNA is a potential marker for radioresistance.
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Affiliation(s)
- Moa Egelberg
- Division of Surgery, Department of Clinical Sciences Lund, Faculty of MedicineLund UniversitySweden
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Faculty of MedicineLund UniversitySweden
- Department of RadiologyKristianstad HospitalSweden
| | - Tommaso De Marchi
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Faculty of MedicineLund UniversitySweden
| | - Gyula Pekar
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Faculty of MedicineLund UniversitySweden
| | - Lena Tran
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Faculty of MedicineLund UniversitySweden
| | - Pär‐Ola Bendahl
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Faculty of MedicineLund UniversitySweden
| | - Axel Stenmark Tullberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University HospitalUniversity of GothenburgSweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University HospitalUniversity of GothenburgSweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University HospitalUniversity of GothenburgSweden
| | - Marianne Farnebo
- Department of Bioscience and Nutrition & Department of Cell and Molecular BiologyKarolinska InstitutetStockholmSweden
| | - Fredrika Killander
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Faculty of MedicineLund UniversitySweden
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Faculty of MedicineSkåne University HospitalLundSweden
| | - Emma Nimeús
- Division of Surgery, Department of Clinical Sciences Lund, Faculty of MedicineLund UniversitySweden
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Faculty of MedicineLund UniversitySweden
- Division of Surgery, Department of Clinical Sciences Lund, Faculty of MedicineSkåne University HospitalLundSweden
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3
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Stenmark Tullberg A, Sjöström M, Tran L, Niméus E, Killander F, Kovács A, Lundstedt D, Holmberg E, Karlsson P. Combining histological grade, TILs, and the PD-1/PD-L1 pathway to identify immunogenic tumors and de-escalate radiotherapy in early breast cancer: a secondary analysis of a randomized clinical trial. J Immunother Cancer 2023; 11:e006618. [PMID: 37208129 PMCID: PMC10201214 DOI: 10.1136/jitc-2022-006618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND The implementation of immunological biomarkers for radiotherapy (RT) individualization in breast cancer requires consideration of tumor-intrinsic factors. This study aimed to investigate whether the integration of histological grade, tumor-infiltrating lymphocytes (TILs), programmed cell death protein-1 (PD-1), and programmed death ligand-1 (PD-L1) can identify tumors with aggressive characteristics that can be downgraded regarding the need for RT. METHODS The SweBCG91RT trial included 1178 patients with stage I-IIA breast cancer, randomized to breast-conserving surgery with or without adjuvant RT, and followed for a median time of 15.2 years. Immunohistochemical analyses of TILs, PD-1, and PD-L1 were performed. An activated immune response was defined as stromal TILs ≥10% and PD-1 and/or PD-L1 expression in ≥1% of lymphocytes. Tumors were categorized as high-risk or low-risk using assessments of histological grade and proliferation as measured by gene expression. The risk of ipsilateral breast tumor recurrence (IBTR) and benefit of RT were then analyzed with 10 years follow-up based on the integration of immune activation and tumor-intrinsic risk group. RESULTS Among high-risk tumors, an activated immune infiltrate was associated with a reduced risk of IBTR (HR 0.34, 95% CI 0.16 to 0.73, p=0.006). The incidence of IBTR in this group was 12.1% (5.6-25.0) without RT and 4.4% (1.1-16.3) with RT. In contrast, the incidence of IBTR in the high-risk group without an activated immune infiltrate was 29.6% (21.4-40.2) without RT and 12.8% (6.6-23.9) with RT. Among low-risk tumors, no evidence of a favorable prognostic effect of an activated immune infiltrate was seen (HR 2.0, 95% CI 0.87 to 4.6, p=0.100). CONCLUSIONS Integrating histological grade and immunological biomarkers can identify tumors with aggressive characteristics but a low risk of IBTR despite a lack of RT boost and systemic therapy. Among high-risk tumors, the risk reduction of IBTR conferred by an activated immune infiltrate is comparable to treatment with RT. These findings may apply to cohorts dominated by estrogen receptor-positive tumors.
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Affiliation(s)
- Axel Stenmark Tullberg
- Department of Oncology, University of Gothenburg Institute of Clinical Sciences, Goteborg, Sweden
| | - Martin Sjöström
- Department of Radiation Oncology, UCSF, San Francisco, California, USA
- Department of Clinical Sciences Lund, Oncology/Pathology and Surgery, Lund University, Lund, Sweden
| | - Lena Tran
- Department of Clinical Sciences Lund, Oncology/Pathology and Surgery, Lund University, Lund, Sweden
| | - Emma Niméus
- Department of Clinical Sciences Lund, Oncology/Pathology and Surgery, Lund University, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Fredrika Killander
- Department of Clinical Sciences Lund, Oncology/Pathology and Surgery, Lund University, Lund, Sweden
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - Anikó Kovács
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dan Lundstedt
- Department of Oncology, University of Gothenburg Institute of Clinical Sciences, Goteborg, Sweden
| | - Erik Holmberg
- Department of Oncology, University of Gothenburg Institute of Clinical Sciences, Goteborg, Sweden
| | - Per Karlsson
- Department of Oncology, University of Gothenburg Institute of Clinical Sciences, Goteborg, Sweden
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Stenmark Tullberg A, Sjöström M, Niméus E, Killander F, Chang SL, Feng FY, Speers CW, Pierce LJ, Kovács A, Lundstedt D, Holmberg E, Karlsson P. Integrating Tumor-Intrinsic and Immunologic Factors to Identify Immunogenic Breast Cancers from a Low-Risk Cohort: Results from the Randomized SweBCG91RT Trial. Clin Cancer Res 2023; 29:1783-1793. [PMID: 37071498 PMCID: PMC10150244 DOI: 10.1158/1078-0432.ccr-22-2746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/18/2022] [Accepted: 01/20/2023] [Indexed: 04/19/2023]
Abstract
PURPOSE The local immune infiltrate's influence on tumor progression may be closely linked to tumor-intrinsic factors. The study aimed to investigate whether integrating immunologic and tumor-intrinsic factors can identify patients from a low-risk cohort who may be candidates for radiotherapy (RT) de-escalation. EXPERIMENTAL DESIGN The SweBCG91RT trial included 1,178 patients with stage I to IIA breast cancer, randomized to breast-conserving surgery with or without adjuvant RT, and followed for a median of 15.2 years. We trained two models designed to capture immunologic activity and immunomodulatory tumor-intrinsic qualities, respectively. We then analyzed if combining these two variables could further stratify tumors, allowing for identifying a subgroup where RT de-escalation is feasible, despite clinical indicators of a high risk of ipsilateral breast tumor recurrence (IBTR). RESULTS The prognostic effect of the immunologic model could be predicted by the tumor-intrinsic model (Pinteraction = 0.01). By integrating measurements of the immunologic- and tumor-intrinsic models, patients who benefited from an active immune infiltrate could be identified. These patients benefited from standard RT (HR, 0.28; 95% CI, 0.09-0.85; P = 0.025) and had a 5.4% 10-year incidence of IBTR after irradiation despite high-risk genomic indicators and a low frequency of systemic therapy. In contrast, high-risk tumors without an immune infiltrate had a high 10-year incidence of IBTR despite RT treatment (19.5%; 95% CI, 12.2-30.3). CONCLUSIONS Integrating tumor-intrinsic and immunologic factors may identify immunogenic tumors in early-stage breast cancer populations dominated by ER-positive tumors. Patients who benefit from an activated immune infiltrate may be candidates for RT de-escalation.
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Affiliation(s)
- Axel Stenmark Tullberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Martin Sjöström
- Department of Clinical Sciences Lund, Oncology/Pathology and Surgery, Lund University, Lund, Sweden
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Emma Niméus
- Department of Clinical Sciences Lund, Oncology/Pathology and Surgery, Lund University, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Fredrika Killander
- Department of Clinical Sciences Lund, Oncology/Pathology and Surgery, Lund University, Lund, Sweden
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | | | - Felix Y. Feng
- University of California San Francisco, San Francisco, California
| | | | - Lori J. Pierce
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Anikó Kovács
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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Tutzauer J, Sjöström M, Holmberg E, Karlsson P, Killander F, Leeb-Lundberg LMF, Malmström P, Niméus E, Fernö M, Jögi A. Breast cancer hypoxia in relation to prognosis and benefit from radiotherapy after breast-conserving surgery in a large, randomised trial with long-term follow-up. Br J Cancer 2022; 126:1145-1156. [PMID: 35140341 PMCID: PMC9023448 DOI: 10.1038/s41416-021-01630-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 10/17/2021] [Accepted: 11/03/2021] [Indexed: 12/21/2022] Open
Abstract
Background Breast-conserving surgery followed by radiotherapy is part of standard treatment for early-stage breast cancer. Hypoxia is common in cancer and may affect the benefit of radiotherapy. Cells adapt to hypoxic stress largely via the transcriptional activity of hypoxia-inducible factor (HIF)-1α. Here, we aim to determine whether tumour HIF-1α-positivity and hypoxic gene-expression signatures associated with the benefit of radiotherapy, and outcome. Methods Tumour HIF-1α-status and expression of hypoxic gene signatures were retrospectively analysed in a clinical trial where 1178 women with primary T1-2N0M0 breast cancer were randomised to receive postoperative radiotherapy or not and followed 15 years for recurrence and 20 years for breast cancer death. Results The benefit from radiotherapy was similar in patients with HIF-1α-positive and -negative primary tumours. Both ipsilateral and any breast cancer recurrence were more frequent in women with HIF-1α-positive primary tumours (hazard ratio, HR0–5 yrs1.9 [1.3–2.9], p = 0.003 and HR0–5 yrs = 2.0 [1.5–2.8], p < 0.0001). Tumour HIF-1α-positivity is also associated with increased breast cancer death (HR0–10 years 1.9 [1.2–2.9], p = 0.004). Ten of the 11 investigated hypoxic gene signatures correlated positively to HIF-1α-positivity, and 5 to increased rate/risk of recurrence. Conclusions The benefit of postoperative radiotherapy persisted in patients with hypoxic primary tumours. Patients with hypoxic primary breast tumours had an increased risk of recurrence and breast cancer death.
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Affiliation(s)
- Julia Tutzauer
- Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Martin Sjöström
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Fredrika Killander
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | | | - Per Malmström
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Emma Niméus
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Division of Surgery, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Department of Surgery Malmö, Skåne University Hospital, Malmö, Sweden
| | - Mårten Fernö
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Annika Jögi
- Translational Cancer Research, Department of Laboratory Medicine, Lund University Cancer Center at Medicon Village, Lund University, Lund, Sweden. .,Skåne University Hospital, Malmö, Sweden.
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Stenmark Tullberg A, Puttonen HAJ, Sjöström M, Holmberg E, Chang SL, Feng FY, Speers C, Pierce LJ, Lundstedt D, Killander F, Niméus E, Kovács A, Karlsson P. Immune Infiltrate in the Primary Tumor Predicts Effect of Adjuvant Radiotherapy in Breast Cancer; Results from the Randomized SweBCG91RT Trial. Clin Cancer Res 2020; 27:749-758. [PMID: 33148672 DOI: 10.1158/1078-0432.ccr-20-3299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/01/2020] [Accepted: 10/30/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Tumor-infiltrating immune cells play a key role in tumor progression. The purpose of this study was to analyze whether the immune infiltrate predicts benefit from postoperative radiotherapy in a large randomized breast cancer radiotherapy trial. EXPERIMENTAL DESIGN In the SweBCG91RT trial, patients with stage I and II breast cancer were randomized to breast-conserving surgery (BCS) and postoperative radiotherapy or to BCS only and followed for a median time of 15.2 years. The primary tumor immune infiltrate was quantified through two independent methods: IHC and gene expression profiling. For IHC analyses, the absolute stromal area occupied by CD8+ T cells and FOXP3+ T cells, respectively, was used to define the immune infiltrate. For gene expression analyses, immune cells found to be prognostic in independent datasets were pooled into two groups consisting of antitumoral and protumoral immune cells, respectively. RESULTS An antitumoral immune response in the primary tumor was associated with a reduced risk of breast cancer recurrence and predicted less benefit from adjuvant radiotherapy. The interaction between radiotherapy and immune phenotype was significant for any recurrence in both the IHC and gene expression analyses (P = 0.039 and P = 0.035) and was also significant for ipsilateral breast tumor recurrence in the gene expression analyses (P = 0.025). CONCLUSIONS Patients with an antitumoral immune infiltrate in the primary tumor have a reduced risk of any recurrence and may derive less benefit from adjuvant radiotherapy. These results may impact decisions regarding postoperative radiotherapy in early breast cancer.
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Affiliation(s)
- Axel Stenmark Tullberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Henri A J Puttonen
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Martin Sjöström
- Department of Clinical Sciences Lund, Oncology/Pathology and Surgery, Lund University, Lund, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Felix Y Feng
- University of California San Francisco, San Francisco, California
| | - Corey Speers
- Department of Radiation Oncology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Lori J Pierce
- Department of Radiation Oncology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Fredrika Killander
- Department of Clinical Sciences Lund, Oncology/Pathology and Surgery, Lund University, Lund, Sweden
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - Emma Niméus
- Department of Clinical Sciences Lund, Oncology/Pathology and Surgery, Lund University, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Anikó Kovács
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Sjöström M, Veenstra C, Holmberg E, Karlsson P, Killander F, Malmström P, Niméus E, Fernö M, Stål O. Expression of HGF, pMet, and pAkt is related to benefit of radiotherapy after breast-conserving surgery: a long-term follow-up of the SweBCG91-RT randomised trial. Mol Oncol 2020; 14:2713-2726. [PMID: 32946618 PMCID: PMC7607179 DOI: 10.1002/1878-0261.12803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/19/2020] [Accepted: 09/11/2020] [Indexed: 01/15/2023] Open
Abstract
Experimental studies suggest that hepatocyte growth factor (HGF) and its transmembrane tyrosine kinase receptor, Met, in part also relying on Akt kinase activity, mediate radioresistance. We investigated the importance of these biomarkers for the risk of ipsilateral breast tumour recurrence (IBTR) after adjuvant radiotherapy (RT) in primary breast cancer. HGF, phosphorylated Met (pMet) and phosphorylated Akt (pAkt) were evaluated immunohistochemically on tissue microarrays from 1004 patients in the SweBCG91‐RT trial, which randomly assigned patients to breast‐conserving therapy, with or without adjuvant RT. HGF was evaluated in the stroma (HGFstr); pMet in the membrane (pMetmem); HGF, pMet and pAkt in the cytoplasm (HGFcyt, pMetcyt, pAktcyt); and pAkt in the nucleus (pAktnuc). The prognostic and treatment predictive effects were evaluated to primary endpoint IBTR as first event during the first 5 years. Patients with tumours expressing low levels of HGFcyt and pMetcyt and high levels of pAktnuc derived a larger benefit from RT [hazard ratio (HR): 0.11 (0.037–0.30), 0.066 (0.016–0.28) and 0.094 (0.028–0.31), respectively] compared to patients with high expression of HGFcyt and pMetcyt, and low pAktnuc [HR: 0.36 (0.19–0.67), 0.35 (0.20–0.64) and 0.47 (0.32–0.71), respectively; interaction analyses: P = 0.052, 0.035 and 0.013, respectively]. These differences remained in multivariable analysis when adjusting for patient age, tumour size, histological grade, St Gallen subtype and systemic treatment (interaction analysis, P‐values: 0.085, 0.027, and 0.023, respectively). This study suggests that patients with immunohistochemically low HGFcyt, low pMetcyt and high pAktnuc may derive an increased benefit from RT after breast‐conserving surgery concerning the risk of developing IBTR.
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Affiliation(s)
- Martin Sjöström
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
| | - Cynthia Veenstra
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Oncology, Linköping University, Linköping, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Fredrika Killander
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Per Malmström
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Emma Niméus
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden.,Division of Surgery, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Mårten Fernö
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
| | - Olle Stål
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Oncology, Linköping University, Linköping, Sweden
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Mehmeti-Ajradini M, Bergenfelz C, Larsson AM, Carlsson R, Riesbeck K, Ahl J, Janols H, Wullt M, Bredberg A, Källberg E, Björk Gunnarsdottir F, Rydberg Millrud C, Rydén L, Paul G, Loman N, Adolfsson J, Carneiro A, Jirström K, Killander F, Bexell D, Leandersson K. Human G-MDSCs are neutrophils at distinct maturation stages promoting tumor growth in breast cancer. Life Sci Alliance 2020; 3:3/11/e202000893. [PMID: 32958605 PMCID: PMC7536824 DOI: 10.26508/lsa.202000893] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/10/2020] [Accepted: 09/10/2020] [Indexed: 12/16/2022] Open
Abstract
This study shows that immunosuppressive primary breast cancer patient–derived G-MDSCs (PMN-MDSCs) are neutrophils at a range of maturations stages, and provides in vivo evidence for that human G-MDSCs also promote tumor growth and myeloid immune cell exclusion. Myeloid-derived suppressor cells (MDSCs) are known to contribute to immune evasion in cancer. However, the function of the human granulocytic (G)-MDSC subset during tumor progression is largely unknown, and there are no established markers for their identification in human tumor specimens. Using gene expression profiling, mass cytometry, and tumor microarrays, we here demonstrate that human G-MDSCs occur as neutrophils at distinct maturation stages, with a disease-specific profile. G-MDSCs derived from patients with metastatic breast cancer and malignant melanoma display a unique immature neutrophil profile, that is more similar to healthy donor neutrophils than to G-MDSCs from sepsis patients. Finally, we show that primary G-MDSCs from metastatic breast cancer patients co-transplanted with breast cancer cells, promote tumor growth, and affect vessel formation, leading to myeloid immune cell exclusion. Our findings reveal a role for human G-MDSC in tumor progression and have clinical implications also for targeted immunotherapy.
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Affiliation(s)
| | - Caroline Bergenfelz
- Division of Experimental Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Anna-Maria Larsson
- Division of Oncology, Department of Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden.,Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Robert Carlsson
- Translational Neurology, Department of Clinical Sciences and Wallenberg Centrum for Molecular Medicine, Lund University, Lund, Sweden
| | - Kristian Riesbeck
- Department of Translational Medicine, Clinical Microbiology, Lund University, Malmö, Sweden
| | - Jonas Ahl
- Department of Infectious Diseases, Department of Translational Medicine, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Helena Janols
- Department of Infectious Diseases, Department of Translational Medicine, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Marlene Wullt
- Department of Infectious Diseases, Department of Translational Medicine, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Anders Bredberg
- Department of Translational Medicine, Clinical Microbiology, Lund University, Malmö, Sweden
| | - Eva Källberg
- Department of Translational Medicine, Cancer Immunology, Lund University, Malmö, Sweden
| | | | | | - Lisa Rydén
- Division of Oncology, Department of Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden.,Department of Surgery and Gastroenterology, Skåne University Hospital, Lund, Sweden
| | - Gesine Paul
- Translational Neurology, Department of Clinical Sciences and Wallenberg Centrum for Molecular Medicine, Lund University, Lund, Sweden
| | - Niklas Loman
- Division of Oncology, Department of Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden.,Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Jörgen Adolfsson
- Science for Life Laboratory Node at Linköping's University, Linköping, Sweden
| | - Ana Carneiro
- Division of Oncology, Department of Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden.,Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Karin Jirström
- Department of Clinical Sciences, Oncology and Therapeutic Pathology, Lund University, Lund, Sweden
| | - Fredrika Killander
- Division of Oncology, Department of Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden.,Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Daniel Bexell
- Division of Translational Cancer Research, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Karin Leandersson
- Department of Translational Medicine, Cancer Immunology, Lund University, Malmö, Sweden
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Stenmark Tullberg A, Nimeus-Malmström E, Killander F, Sjöström M, Puttonen HA, Feng FY, Kovacs A, Lundstedt D, Holmberg E, Karlsson P. Tumor-infiltrating lymphocytes in ipsilateral breast tumor recurrences predict prognosis. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
546 Background: The antitumoral immune response is dynamic and changes with tumor progression. Previous studies show that immunohistochemical (IHC) assessment of TILs in local recurrences can predict prognosis. It is not clear how adjuvant radiotherapy (RT) can alter the local immune response or if gene expression analyses of TILs in recurrences can provide prognostic information. Methods: Matched biopsies from primary tumors and ipsilateral breast tumor recurrences (IBTRs) from the randomized SweBCG91RT trial were assessed for TILs. Analyses were performed using gene expression (86 matched pairs) and IHC assessment (126 matched pairs). Results: The median time to IBTR was 8.0 years among irradiated patients and 3.6 years among unirradiated patients. In the gene expression analyses, higher absolute values of CD8+ T cells, CD4+ effector memory and CD8+ effector memory T cells in the recurrence could significantly predict a decreased risk of subsequent distant metastasis. In addition, a net increase of these cells in the IBTR compared to the primary tumor was associated with a significantly lower risk of metastasis. TILs did not change significantly between the matched tumors for the whole group or among irradiated patients versus unirradiated patients in the gene expression or IHC analyses. Surprisingly, the group with unchanged TILs levels as measured by IHC had the lowest risk of metastasis while an increase or a decrease in TILs was significantly associated with an increased risk. Conclusions: Cytotoxic and memory T cells in the recurrence protect against subsequent distant metastasis although IHC measurement of TILs could not confirm these results. No significant differences in TILs infiltration between irradiated versus unirradiated patients could be determined in the recurrences. Further analyses including changes of subtypes between the primary tumor and the recurrence will be presented.
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Affiliation(s)
| | - Emma Nimeus-Malmström
- Department of Clinical Sciences, Oncology/ Pathology and Surgery, Lund University, Lund, Sweden
| | | | - Martin Sjöström
- Lund University, Department of Oncology and Pathology, Lund, Sweden
| | | | - Felix Y Feng
- Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | - Aniko Kovacs
- Sahlgrenska University Hospital, Department of Clinical Pathology, Gothenburg, Sweden
| | - Dan Lundstedt
- Department of Oncology, Sahlgrenska University Hospital, Göteborg, Sweden
| | | | - Per Karlsson
- Sahlgrenska Academy, Sahlgrenska University Hospital, Department of Oncology, Gothenburg, Sweden
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10
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Kornalijnslijper-Altena R, Andersson A, Brandberg Y, Kessler LE, Elinder E, Hartman J, Hellstrom M, Johansson H, Killander F, Linderholm BK, Lindman H, Valachis A, Wennstig AK, Xie H, Hatschek T, Bergh JCS. PREDIX II HER2: Improving pre-operative systemic therapy for human epidermal growth factor receptor 2 (HER2) amplified breast cancer (BC). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.tps605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS605 Background: Neo-adjuvant systemic therapy (NAT) is the standard of care for most patients with early HER2-amplified and triple negative breast cancer (BC). Increasing the rate of pathological complete response (pCR) is highly meaningful for those patients, as pCR is strongly predictive for improved long-term disease-related outcomes. Clinical and preclinical evidence support the hypothesis that pCR-rates may be augmented by the addition of checkpoint inhibitors, such as monoclonal antibodies targeting the Programmed Death Ligand receptor 1 (PD-L1), to standard systemic NAT. Studies in different BC patient cohorts (e.g., IMPassion130, PANACEA, KATE2) have indicated that PD-L1 protein expression on tumor-infiltrating lymphocytes (TIL’s) is a predictive marker for checkpoint inhibitor efficacy. Methods: We have initiated a phase II open-label, 2:1 randomized clinical trial where women with early HER2-amplified, PD-L1+ BC (cT2-3 and/or cN+) are treated with standard NAT (composed of anti-HER2 antibodies with a chemotherapy backbone of sequentially taxanes + carboplatin and epirubicin + cyclophosphamide [EC]) +/- atezolizumab during EC. N = 190 patients will be accrued in nine centers in Sweden to be able to demonstrate a 20% increase in pCR-rate, with a power of 80% and a two-sided alpha of 10%. Firstly, a prescreening is performed to select patients with a PD-L1 expression of > 1% on TIL’s. Important exclusion criteria are significant organ dysfunction and (with some exceptions) active auto-immune diseases. Extensive translational side-studies are performed to explore predictive markers for treatment efficacy, including clinicopathologic studies, molecular imaging and microbiome analyses, as well as monitoring of acute and chronic treatment-related toxicity, objective cognitive function and quality of life. As of February 11th, 4 patients have been prescreened and 1 enrolled in the trial. The clinical trial registry number is NCT03894007. Clinical trial information: NCT03894007 .
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Affiliation(s)
| | | | - Yvonne Brandberg
- Karolinska Institutet, Department of Oncology-Pathology (OnkPat), Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Johan Hartman
- Karolinska Institutet and University Laboratory, Stockholm, Sweden
| | - Mats Hellstrom
- Karolinska University Hospital, Clinical Trial Unit Oncology, Stockholm, Sweden
| | - Hemming Johansson
- Department of Oncology, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | | | | | - Henrik Lindman
- Department of Oncology, Uppsala University, Uppsala, Sweden
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11
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Killander F, Wieslander E, Karlsson P, Holmberg E, Lundstedt D, Holmberg L, Werner L, Koul S, Haghanegi M, Kjellen E, Nilsson P, Malmström P. No Increased Cardiac Mortality or Morbidity of Radiation Therapy in Breast Cancer Patients After Breast-Conserving Surgery: 20-Year Follow-up of the Randomized SweBCGRT Trial. Int J Radiat Oncol Biol Phys 2020; 107:701-709. [PMID: 32302682 DOI: 10.1016/j.ijrobp.2020.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 04/02/2020] [Accepted: 04/04/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Radiation therapy (RT) after breast-conserving surgery reduces locoregional recurrences and improves survival but may cause late side effects. The main purpose of this paper was to investigate long-term side effects after whole breast RT in a randomized clinical trial initiated in 1991 and to report dose-volume data based on individual 3-dimensional treatment plans for organs at risk. METHODS AND MATERIALS The trial included 1187 patients with T1-2 N0 breast cancer randomized to postoperative tangential whole breast RT or no further treatment. The prescription dose to the clinical target volume was 48 to 54 Gy. We present 20-year follow-up on survival, cause of death, morbidity, and later malignancies. For a cohort of patients (n = 157) with accessible computed tomography-based 3-dimensional treatment plans in Dicom-RT format, dose-volume descriptors for organs at risk were derived. In addition, these were compared with dose-volume data for a cohort of patients treated with contemporary RT techniques. RESULTS The cumulative incidence of cardiac mortality was 12.4% in the control group and 13.0% in the RT group (P = .8). There was an increase in stroke mortality: 3.4% in the control group versus 6.7% in the RT group (P = .018). Incidences of contralateral breast cancer and lung cancer were similar between groups. The median Dmean (range) heart dose for left-sided treatments was 3.0 Gy (1.1-8.1), and the corresponding value for patients treated in 2017 was 1.5 Gy (0.4-6.0). CONCLUSIONS In this trial, serious late side effects of whole breast RT were limited and less than previously reported in large meta-analyses. We observed no increase in cardiac mortality in irradiated patients. Doses to the heart were a median Dmean of 3.0 Gy for left-sided RT. The observed increase in stroke mortality may partly be secondary to cardiac side effects, complications to anticoagulant treatment, or to chance, rather than a direct side effect of tangential whole breast irradiation.
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Affiliation(s)
- Fredrika Killander
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden; Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.
| | - Elinore Wieslander
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Regional Oncologic Centre West, Gothenburg, Sweden
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Holmberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Translational Oncology & Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, Kingś College London, London, United Kingdom
| | - Linda Werner
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden
| | - Sasha Koul
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Mahnaz Haghanegi
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Elisabeth Kjellen
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden; Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Per Nilsson
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Per Malmström
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden; Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
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12
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Mehmeti M, Bergenfelz C, Bexell D, Carlsson R, Hellsten R, Larsson AM, Loman N, Riesbeck K, Ahl J, Rydberg-Millrud C, Paul-Visse G, Rydén L, Killander F, Leandersson K. Abstract A73: Human granulocytic myeloid-derived suppressor cells (G-MDSCs) in metastatic breast cancer patients is a heterogeneous population with angiogenic potential in vivo. Cancer Immunol Res 2020. [DOI: 10.1158/2326-6074.tumimm18-a73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
MDSCs are potent immunosuppressive myeloid cells that have been implicated in various diseases, including cancer. In humans, MDSCs are divided into Mo-GMDSCs and G-MDSCs subgroups, depending on their surface phenotype and function. While their immunosuppressive properties have been extensively studied, knowledge about their origin and their tumor-promoting functions per se remains scarce. In this study, we demonstrate that G-MDSCs are significantly enriched in the peripheral blood of locoregional recurrent metastatic breast cancer (LRR/MBC) compared to healthy donors. The G-MDSCs display a heterogeneous population with a morphology representing one blast-like and one polymorphonuclear (PMN) population. In a breast cancer xenograft model, co-transplanting G-MDSCs sorted from LRR/MBC together with breast cancer cells significantly promoted angiogenesis and tumor growth. Gene expression profiling analysis revealed that G-MDSCs from LRR/MBC rather clustered with neutrophils from healthy donors, sharing similar expression in genes relevant for angiogenesis, lymphangiogenesis and immunosuppression, but surprisingly not with G-MDSCs from sepsis patients. We conclude that enrichment of G-MDSCs in metastatic breast cancer represents a heterogeneous population of activated neutrophils that can promote angiogenesis and tumor progression, and immature blasts of yet unknown character.
Citation Format: Meliha Mehmeti, Caroline Bergenfelz, Daniel Bexell, Robert Carlsson, Rebecka Hellsten, Anna-Maria Larsson, Niklas Loman, Kristian Riesbeck, Jonas Ahl, Camilla Rydberg-Millrud, Gesine Paul-Visse, Lisa Rydén, Fredrika Killander, Karin Leandersson. Human granulocytic myeloid-derived suppressor cells (G-MDSCs) in metastatic breast cancer patients is a heterogeneous population with angiogenic potential in vivo [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2018 Nov 27-30; Miami Beach, FL. Philadelphia (PA): AACR; Cancer Immunol Res 2020;8(4 Suppl):Abstract nr A73.
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Affiliation(s)
- Meliha Mehmeti
- 1Department of Translational Medicine, Cancer Immunology, Lund University, Malmö, Sweden,
| | - Caroline Bergenfelz
- 2Department of Translational Medicine, Division of Experimental Infection Medicine, Lund University, Malmö, Sweden,
| | - Daniel Bexell
- 3Translational Cancer Research, Lund University, Lund, Sweden,
| | | | | | - Anna-Maria Larsson
- 6Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden,
| | - Niklas Loman
- 6Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden,
| | | | - Jonas Ahl
- 8Department of Infectious Diseases, Lund University, Malmö, Sweden
| | | | | | - Lisa Rydén
- 6Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden,
| | - Fredrika Killander
- 6Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden,
| | - Karin Leandersson
- 1Department of Translational Medicine, Cancer Immunology, Lund University, Malmö, Sweden,
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Malmberg M, Larsson C, Vallon-Christersson J, Ehinger A, Hegardt C, Killander F, Ryden L, Saal LH, Loman N, Borg Å. Abstract P1-18-10: Preoperative treatment of HER2-positive breast cancer in South Sweden. A retrospective, comprehensive survey of neo-adjuvant treated HER2-positve breast cancer in the SCAN-B project 2010-2017. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-p1-18-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: Over the last few years, neoadjuvant therapy has become a standard of care in HER2-positive early breast cancer. This standard has recently been confirmed by the St. Gallen Consensus for stage II and III HER2-positive disease. In neoadjuvant treatment adding anti HER2 treatment almost doubled the pathological complete response (pCR) rate. Later studies have shown a better outcome for patients achieving a pCR compared with those with a non-pCR. The aim of this study is to present a comprehensive description of preoperative treatment in HER2-positive, according to ASCO and Swedish guidelines, breast cancer with detail treatment routines, choice of drugs and regimens as well as adherence to national guidelines and treatment changes over time.
Material: During the period October 2010 to December 2017 6572 patients with early breast cancer were diagnosed in the Skåne region of South Sweden and included in the SCAN-B project (Sweden Cancerome Analysis Network - Breast project, ClinicalTrials.gov identifier NCT02306096). The SCAN-B project is a population based study that during the period included 76.7% of all primary breast cancer patients in the catchment area. The majority of all tumors have been analyzed by NGS-based RNA sequencing, RNAseq.
Results: Of the 6572 patients 672 (10.2%) were HER2 positive and of these 101 (15%) were treated in a neoadjuvant setting with chemotherapy and HER2 directed antibodies. The proportion of HER2-positive patients receiving neoadjuvant treatment with trastuzumab increased from 9% in 2010 to 29% in 2017. Patient age was 27 to 89 years, median age 54 years. Pertuzumab was introduced in 2016 and in 2017 85% of patients received the combination of trastuzumab and pertuzumab. At diagnosis tumor stage T1, T2, T3 and T4d was 19%, 60%, 14% and 5% respectively and 50% were node negative at sentinel node biopsy pre treatment. Of tumors 52% were estrogen receptor positive (ie >10% stained nuclei). During the neoadjuvant treatment period 31 patients were hospitalized at median 2 times for toxicity and a total of medium 4.7 days. At surgery 62% had a mastectomy and 38% breast conserving surgery. Follow up time is median 3.9 years and overall survival 94%.
Conclusions: This retrospective analysis of neoadjuvant treated HER2-positive breast cancer patients shows a gradual increase of neoadjuvant treatment and a very fast implementation of pertuzumab when it became available in Sweden. Overall survival is high but the follow up time is short and the material to small to analyze subgroups. Data on tumor RNAseq will be presented.
Citation Format: Martin Malmberg, Christer Larsson, Johan Vallon-Christersson, Anna Ehinger, Cecilia Hegardt, Fredrika Killander, Lisa Ryden, Lao H. Saal, Niklas Loman, Åke Borg. Preoperative treatment of HER2-positive breast cancer in South Sweden. A retrospective, comprehensive survey of neo-adjuvant treated HER2-positve breast cancer in the SCAN-B project 2010-2017 [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 P1-18-10.
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Affiliation(s)
| | | | | | - Anna Ehinger
- 4Department of Clinical Genetics and Pathology, Lund University Hospital, Sweden
| | - Cecilia Hegardt
- 5Lund University Cancer Center, Medicon Village, Lund University, Sweden
| | | | - Lisa Ryden
- 6Department of Surgery, Lund University Hospital, Sweden
| | - Lao H. Saal
- 5Lund University Cancer Center, Medicon Village, Lund University, Sweden
| | - Niklas Loman
- 1Dept. of Oncology, Lund University Hospital, Sweden
| | - Åke Borg
- 5Lund University Cancer Center, Medicon Village, Lund University, Sweden
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Tullberg AS, Puttonen HAJ, Holmberg E, Lundstedt D, Killander F, Niméus E, Kóvacs A, Karlsson P. Abstract PD6-10: A high ratio of CD8/FOXP3 predicts an unfavorable response to postoperative radiotherapy after breast-conserving surgery: Results from the randomized SweBCG91RT trial. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-pd6-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Purpose: The effect of postoperative radiotherapy (RT) based on the immune phenotype of tumor-infiltrating lymphocytes (TILs) has not been investigated. The purpose of this study was to analyze how the balance between CD8+ T cells and T regulatory cells (FOXP3+), which have opposite effects on the anti-tumoral defense, affects the risk of ipsilateral breast tumor recurrence (IBTR) and of any recurrence as well as the interaction with RT in a large randomized RT trial.
Methods: In the SweBCG91RT trial, patients with breast cancer stage I and II were randomized to breast conserving surgery (BCS) and postoperative RT or BCS only and followed for a median time of 15.2 years. Tumor blocks were retrieved and stromal TILs were assessed through hematoxylin-eosin stained slides. CD8+ T cells and T regulatory cells were evaluated through staining for CD8 and FOXP3 and the percentage of stroma occupied by CD8+ T cells and T regulatory cells respectively was then calculated. Cutoffs at 5% and 2.5% were used to define high levels of CD8+ T cells (CD8High) and T regulatory cells (FOXP3High), respectively. In total, 943 patients were analyzed.
Results: Among patients who did not receive RT, an increased risk of IBTR and of any recurrence was seen in the CD8Low/FOXP3Low (HR 2.64, CI95% 1.26-5.56, p=0.010 and HR 2.52, CI95% 1.34-4.77, p=0.004, respectively) and CD8High/FOXP3High (HR 1.94, CI95% 0.81-4.63, p=0.135 and HR 2.76, CI95% 1.36-5.57, p=0.005, respectively) groups compared to CD8High/FOXP3Low (HR 1.0) in multivariable analyses including grade and age. The effect of RT on risk of IBTR was more pronounced in the groups with CD8Low/FOXP3Low (HR 0.37, CI95% 0.24-0.57, p<0.001) and CD8High/FOXP3High (HR 0.43, CI95% 0.16-1.13, p=0.086) compared to CD8High/FOXP3Low (HR 0.92, CI95% 0.25-3.40, p=0.905). A potentially unfavorable effect of RT on the risk of any recurrence was observed in the CD8High/FOXP3Low (HR 1.74, CI95% 0.75-4.06, p=0.20) group in contrast to the effect of RT in patients with CD8High/FOXP3High (HR 0.53, CI95% 0.28-1.01, p=0.054) and CD8Low/FOXP3Low (HR 0.48, CI95% 0.34-0.68, p<0.001). A significant interaction between immune phenotype and the effect of RT was found for any recurrence (p=0.024) but not for IBTR (p=0.66).
Conclusions: Our findings suggest that patients with a favorable immune phenotype (CD8High/FOXP3Low) may not derive any benefit from adjuvant RT which could be explained by an interaction through which RT may suppress an activated immune response. These results may have an impact on decisions regarding postoperative RT in early breast cancer.
Citation Format: Axel Stenmark Tullberg, Henri AJ Puttonen, Erik Holmberg, Dan Lundstedt, Fredrika Killander, Emma Niméus, Anikó Kóvacs, Per Karlsson. A high ratio of CD8/FOXP3 predicts an unfavorable response to postoperative radiotherapy after breast-conserving surgery: Results from the randomized SweBCG91RT 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 PD6-10.
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Affiliation(s)
- Axel Stenmark Tullberg
- 1Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Henri AJ Puttonen
- 2Department of Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Erik Holmberg
- 1Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dan Lundstedt
- 1Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Fredrika Killander
- 3Department of Oncology, Department of Clinical Sciences Lund, Oncology/ Pathology and Surgery, Lund University, Skåne, Sweden
| | - Emma Niméus
- 4Department of Clinical Sciences Lund, Oncology/ Pathology and Surgery, Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Anikó Kóvacs
- 2Department of Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Karlsson
- 1Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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15
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Adra J, Lundstedt D, Killander F, Holmberg E, Haghanegi M, Kjellén E, Karlsson P, Alkner S. Distribution of Locoregional Breast Cancer Recurrence in Relation to Postoperative Radiation Fields and Biological Subtypes. Int J Radiat Oncol Biol Phys 2019; 105:285-295. [PMID: 31212042 DOI: 10.1016/j.ijrobp.2019.06.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/28/2019] [Accepted: 06/01/2019] [Indexed: 01/17/2023]
Abstract
PURPOSE To investigate incidence and location of locoregional recurrence (LRR) in patients who have received postoperative locoregional radiation therapy (LRRT) for primary breast cancer. LRR-position in relation to applied radiotherapy and the primary tumor biological subtype were analyzed with the aim of evaluating current target guidelines and radiation therapy techniques in relation to tumor biology. METHODS AND MATERIALS Medical records were reviewed for all patients who received postoperative LRRT for primary breast cancer in southwestern Sweden from 2004 to 2008 (N = 923). Patients with LRR as a first event were identified (n = 57; distant failure and death were considered competing risks). Computed tomographic images identifying LRR were used to compare LRR locations with postoperative LRRT fields. LRR risk and distribution were then related to the primary breast cancer biologic subtype and to current target guidelines. RESULTS Cumulative LRR incidence after 10 years was 7.1% (95% confidence interval [CI], 5.5-9.1). Fifty-seven of the 923 patients in the cohort developed LRR (30 local recurrences and 30 regional recurrences, of which 3 cases were simultaneous local and regional recurrence). Most cases of LRR developed fully (56%) or partially (26%) within postoperatively irradiated areas. The most common location for out-of-field regional recurrence was cranial to radiation therapy fields in the supraclavicular fossa. Patients with an estrogen receptor negative (ER-) (hazard ratio [HR], 4.6; P < .001; 95% CI, 2.5-8.4) or HER2+ (HR, 2.4; P = .007; 95% CI, 1.3-4.7) primary breast cancer presented higher risks of LRR compared with those with ER+ tumors. ER-/HER2+ tumors more frequently recurred in-field (68%) rather than marginally or out-of-field (32%). In addition, 75% of in-field recurrences derived from an ER- or HER+ tumor, compared with 45% of marginal or out-of-field recurrences. A complete pathologic response in the axilla after neoadjuvant treatment was associated with a lower degree of LRR risk (P = .022). CONCLUSIONS Incidence and location of LRR seem to be related to the primary breast cancer biologic subtype. Individualized LRRT according to tumor biology may be applied to improve outcomes.
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Affiliation(s)
- Jamila Adra
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahgrenska University Hospital, Gothenburg, Sweden
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahgrenska University Hospital, Gothenburg, Sweden
| | - Fredrika Killander
- Division of Oncology and Pathology, Institute of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahgrenska University Hospital, Gothenburg, Sweden
| | - Mahnaz Haghanegi
- Division of Oncology and Pathology, Institute of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Elisabeth Kjellén
- Division of Oncology and Pathology, Institute of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahgrenska University Hospital, Gothenburg, Sweden
| | - Sara Alkner
- Division of Oncology and Pathology, Institute of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden.
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Adra J, Karlsson P, Killander F, Lundstedt D, Alkner S. Abstract PD8-11: Distribution of locoregional breast cancer recurrences in relation to previous radiotherapy and biological subtype. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-pd8-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Adjuvant locoregional radiotherapy (LRRT) reduces risk of locoregional failures (LRF) and improves survival for node positive breast cancer (BC) patients. However, LRRT increases the risk for toxicity as edema in the arm, lung cancer and cardiac mortality. Modern radiotherapy allows a more conform therapy which makes knowledge of LRF-patterns very important, in order not to underdose volumes with high risk for microscopic disease and simultaneously restrict dose to risk organs. In addition, BC-subtype may affect radiosensitivity and could possibly be used to individualize LRRT in the future.
Methods: We investigated outcome for BC-patients receiving LRRT in the Southwest Sweden (2004-2008) in order to identify LRFs. During this period patients with >3 positive lymph nodes were given LRRT (50Gy in 2Gy fractions) to the breast/thoracic wall, axilla level II+III, supra- and infraclavicular lymph nodes according to a target definition atlas introduced in 2002. Patients with LRF as first event were identified, with distant failures and death considered as competing risks. The anatomical distribution of LRF was compared with the contouring atlas, radiotherapy given, and biological subtype based on immunohistochemistry.
Results: 904 patients received LRRT. Median follow-up time was 9.8 years (0.2-14.6) for patients without an event. 59 patients (6,5%) developed a LRF, 30 of which were local failures (LF) and 31 regional failures (RF) (2 simultaneous LF/RF). Median time to LRF was 2.8 years. 37 of the 59 (63%) LRF-patients developed generalized disease within 3 months from the LRF. Of the 845 patients without LRF 316 developed distant metastases as first recurrence, 1 an isolated RF in the contralateral axilla, 64 died from other causes, and for 5 patients recurrence-status was unclear. 459 were alive at end of follow-up.
Of the LF 19 developed after mastectomy (MRM) and 11 after breast conserving surgery (BCS). LF-location after MRM: 9 in-field, 6 at field margin, 2 both in/out of field, 1 out of field, and for 1 not yet determined. After BCS: 8 in-field, 1 at field margin, and for 2 not yet determined. Of the RF 28 developed after MRM and 3 after BCS. Location of RF after MRM: 11 in-field, 6 at field margin, 1 both in/out of field, 2 out of field, and for 8 not yet determined. After BCS: 1 in-field, 1 at field margin, and 1 not yet determined. The most common location for RF close to /out of field was superior to the treated area in fossa supraclavicularis.
Biological approximate subtype was available for 885 of the primary tumours; luminal (ER+ and/or PR+ HER2-/?) 67% (589/885), HER2+ 19% (169/885), triple negative (ER- and PR- HER2-/?) (TN) 14% (127/885). Subtype distribution of BC later causing LRF despite LRRT was: luminal 44% (26/59), HER2+ 27% (16/59), TN 29% (17/59). Among primary tumours causing a LRF within irradiated volume 77% (24/31) were HER2+ or TN.
Conclusion: In this high risk cohort of BC-patients, we found a low incidence of LRFs. The majority of LRFs developed within irradiated volume. BCs of the HER2+ and TN-subtype may be more radioresistant and have a higher risk of LRF. Updated information as well as figures mapping all recurrences in relation to previous LRRT will be presented at the symposium.
Citation Format: Adra J, Karlsson P, Killander F, Lundstedt D, Alkner S. Distribution of locoregional breast cancer recurrences in relation to previous radiotherapy and biological subtype [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD8-11.
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Affiliation(s)
- J Adra
- Institute of Clinical Sciences, Sahlgrenska Academy/Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden; Lund University, Faculty of Medicine, Lund, Sweden
| | - P Karlsson
- Institute of Clinical Sciences, Sahlgrenska Academy/Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden; Lund University, Faculty of Medicine, Lund, Sweden
| | - F Killander
- Institute of Clinical Sciences, Sahlgrenska Academy/Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden; Lund University, Faculty of Medicine, Lund, Sweden
| | - D Lundstedt
- Institute of Clinical Sciences, Sahlgrenska Academy/Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden; Lund University, Faculty of Medicine, Lund, Sweden
| | - S Alkner
- Institute of Clinical Sciences, Sahlgrenska Academy/Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden; Lund University, Faculty of Medicine, Lund, Sweden
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Forsare C, Bak M, Falck AK, Grabau D, Killander F, Malmström P, Rydén L, Stål O, Sundqvist M, Bendahl PO, Fernö M. Non-linear transformations of age at diagnosis, tumor size, and number of positive lymph nodes in prediction of clinical outcome in breast cancer. BMC Cancer 2018; 18:1226. [PMID: 30526533 PMCID: PMC6286551 DOI: 10.1186/s12885-018-5123-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 11/22/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Prognostic factors in breast cancer are often measured on a continuous scale, but categorized for clinical decision-making. The primary aim of this study was to evaluate if accounting for continuous non-linear effects of the three factors age at diagnosis, tumor size, and number of positive lymph nodes improves prognostication. These factors will most likely be included in the management of breast cancer patients also in the future, after an expected implementation of gene expression profiling for adjuvant treatment decision-making. METHODS Four thousand four hundred forty seven and 1132 women with primary breast cancer constituted the derivation and validation set, respectively. Potential non-linear effects on the log hazard of distant recurrences of the three factors were evaluated during 10 years of follow-up. Cox-models of successively increasing complexity: dichotomized predictors, predictors categorized into three or four groups, and predictors transformed using fractional polynomials (FPs) or restricted cubic splines (RCS), were used. Predictive performance was evaluated by Harrell's C-index. RESULTS Using FP-transformations, non-linear effects were detected for tumor size and number of positive lymph nodes in univariable analyses. For age, non-linear transformations did, however, not improve the model fit significantly compared to the linear identity transformation. As expected, the C-index increased with increasing model complexity for multivariable models including the three factors. By allowing more than one cut-point per factor, the C-index increased from 0.628 to 0.674. The additional gain, as measured by the C-index, when using FP- or RCS-transformations was modest (0.695 and 0.696, respectively). The corresponding C-indices for these four models in the validation set, based on the same transformations and parameter estimates from the derivation set, were 0.675, 0.700, 0.706, and 0.701. CONCLUSIONS Categorization of each factor into three to four groups was found to improve prognostication compared to dichotomization. The additional gain by allowing continuous non-linear effects modeled by FPs or RCS was modest. However, the continuous nature of these transformations has the advantage of making it possible to form risk groups of any size.
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Affiliation(s)
- Carina Forsare
- Faculty of Medicine, Department of Clinical Sciences Lund, Oncology and Pathology, Lund University, Medicon Village Building 404, Scheelevägen 2, SE-223 81, Lund, Sweden.
| | - Martin Bak
- Department of Pathology, Odense University Hospital, DK-5000, Odense, Denmark
| | - Anna-Karin Falck
- Department of Surgery, Helsingborg Hospital, SE-281 85, Helsingborg, Sweden
| | - Dorthe Grabau
- Department of Pathology, Lund University, Skåne University Hospital, SE-221 85, Lund, Sweden
| | - Fredrika Killander
- Faculty of Medicine, Department of Clinical Sciences Lund, Oncology and Pathology, Lund University, Medicon Village Building 404, Scheelevägen 2, SE-223 81, Lund, Sweden.,Department of Haematology, Oncology and Radiation physics, Skane University Hospital, SE-221 85, Lund, Sweden
| | - Per Malmström
- Faculty of Medicine, Department of Clinical Sciences Lund, Oncology and Pathology, Lund University, Medicon Village Building 404, Scheelevägen 2, SE-223 81, Lund, Sweden.,Department of Haematology, Oncology and Radiation physics, Skane University Hospital, SE-221 85, Lund, Sweden
| | - Lisa Rydén
- Faculty of Medicine, Department of Clinical Sciences Lund, Division of Surgery, Skåne University Hospital, Lund University, SE-221 85, Lund, Sweden.,Department of Surgery and Gastroenterology, Skåne University Hospital, SE-205 02, Malmö, Sweden
| | - Olle Stål
- Department of Clinical and Experimental Medicine and Department of Oncology, Linköping University, SE-581 85, Linköping, Sweden
| | - Marie Sundqvist
- Department of Surgery, County Hospital, SE-391 85, Kalmar, Sweden
| | - Pär-Ola Bendahl
- Faculty of Medicine, Department of Clinical Sciences Lund, Oncology and Pathology, Lund University, Medicon Village Building 404, Scheelevägen 2, SE-223 81, Lund, Sweden
| | - Mårten Fernö
- Faculty of Medicine, Department of Clinical Sciences Lund, Oncology and Pathology, Lund University, Medicon Village Building 404, Scheelevägen 2, SE-223 81, Lund, Sweden
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Wickberg Å, Liljegren G, Killander F, Lindman H, Bjöhle J, Carlberg M, Blomqvist C, Ahlgren J, Villman K. Omitting radiotherapy in women ≥ 65 years with low-risk early breast cancer after breast-conserving surgery and adjuvant endocrine therapy is safe. Eur J Surg Oncol 2018; 44:951-956. [DOI: 10.1016/j.ejso.2018.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/28/2018] [Accepted: 04/05/2018] [Indexed: 11/16/2022] Open
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Gligorov J, Ataseven B, Verrill M, De Laurentiis M, Jung K, Azim H, Al-Sakaff N, Lauer S, Shing M, Pivot X, Koroveshi D, Bouzid K, Casalnuovo M, Cascallar D, Korbenfeld EP, Bastick P, Beith J, Colosimo M, Friedlander M, Ganju V, Green M, Patterson K, Redfern A, Richardson G, Ceric T, Gordana K, Beato CA, Ferrari M, Hegg R, Helena V, Ismael GF, Lessa AE, Mano M, Morelle A, Nogueira JA, Timcheva K, Tomova A, Tsakova M, Zlatareva-Petrova A, Asselah J, Assi H, Brezden-Masley C, Chia S, Freedman O, Harb M, Joy AA, Kulkarni S, Prady C, Gaete AAA, Matamala L, Torres R, Yanez E, Franco S, Urrego M, Gugić D, Vrbanec D, Melichar B, Prausová J, Vyzula R, Pilarte RG, León MI, Muñoz R, Ramos G, Azeem HA, Aziz AA, El Zawahry H, Osegueda FR, Alexandre J, Artignan X, Barletta H, Beguier E, Berdah JF, Marty CB, Bollet M, Bourgeois H, Bressac C, Burki F, Campone M, Coeffic D, Cojocarasu OZ, Dagada C, Dalenc F, Del Piano F, Desauw C, Desmoulins I, Dohollou N, Egreteau J, Ferrero JM, Foa C, Garidi R, Gasnault L, Gligorov J, Guardiola E, Hamizi S, Jarcau R, Jacquin JP, Jaubert D, Jolimoy G, Mineur HL, Largillier R, Leduc B, Martin P, Melis A, Monge J, Moullet I, Mousseau M, Nguyen S, Orfeuvre H, Petit T, Pivot X, Priou F, Bach IS, Simon H, Stefani L, Uwer L, Youssef A, Aktas B, von der Assen A, Augustin D, Balser C, Bauer LE, Bechtner C, Beyer G, Brucker C, Bückner U, Busch S, Christensen B, Deryal M, Farrokh A, Faust E, Friedrichs K, Graf H, Griesshammer M, Grischke EM, Hänle C, Heider A, Henschen S, Hesse T, Jackisch C, Kisro J, Köhler A, Kuemmel S, Lampe D, Lantzsch T, Latos K, Lex B, Liedtke C, Luedders D, Maintz C, Müller V, Overkamp F, Park-Simon TW, Paul M, Prechtl A, Ringsdorf U, Runnebaum I, Ruth S, Salat C, Scheffen I, Schilling J, Schmatloch S, Schmidt M, Schneeweiss A, Schrader I, Seipelt G, Simon E, Stefek A, Stickeler E, Thill M, Tio J, Tuczek A, Warm M, Weigel M, Wischnik A, Wojcinski S, Ziegler-Löhr K, Aravantinos G, Ardavanis A, Fountzilas G, Gogas H, Kakolyris S, Mavroudis D, Papadimitriou C, Papandreou C, Papazisis K, Castro H, Hernandez-Monroy CE, Ngan R, Yeo W, Bittner N, Boer K, Csejtei A, Horvath Z, Kocsis J, Mangel LC, Mezei K, Nagy Z, Szanto J, Atmakusuma D, Fadjari H, Kurnianda D, Prayogo N, Tanggo EH, Coate L, Hennessy B, Kelly C, Martin M, Nasim S, O'Connor M, Aieta M, Allegrini G, Amadori D, Bidoli P, Biti G, Bordonaro R, Bottini A, Carterni G, Cavanna L, Cazzaniga M, Cognetti F, Contu A, Cruciani G, Donadio M, Falcone A, Farci D, Forcignanò RC, Frassoldati A, Gaion F, Gamucci T, Giotta F, de Laurentiis M, Livi L, Lorusso V, Maiello E, Marchetti P, Mariani G, Mion M, Moscetti L, Musolino A, Pazzola A, Pedrazzoli P, Pigi A, de Placido S, Caremoli ER, Santoro A, Tienghi A, Ahn JS, Jung KH, Lee KS, Lee SH, Seo JH, Sohn JH, Cesas A, Juozaityte E, Cheah NLC, Chong FLT, Devi BC, Phua V, Teoh D, Ching LW, Yusof M, Corona J, Dominguez A, Mendoza RLG, Hernandez CA, Ramiro AJ, Santos JM, Espinosa PM, Villarreal Garza CM, Errihani H, Bakker S, van den Berkmortel F, Blaisse R, Huinink DTB, van den Bosch J, Braun J, Dercksen M, Droogendijk H, Erdkamp F, Haringhuizen A, de Jongh F, Kok T, Los M, Madretsma S, Terwogt JMM, van der Padt A, van Rossum-Schornagel QC, Smilde T, de Valk B, van der Velden A, van Warmerdam L, van de Wouw A, North R, Kersten C, Mjaaland I, Wist E, Aziz Z, Masood N, Rashid K, Shah M, Alcedo JC, Aleman D, Neciosup S, Reategui R, Valdiviezo N, Vera L, Fernando G, Roque F, Strebel HM, Krzemieniecki K, Litwiniuk M, Mruk A, Pienkowski T, Sawrycki P, Slomian G, Tomczak P, Afonso N, Cardoso F, Damasceno M, Nave M, Badulescu F, Ciule L, Curescu S, Eniu A, Filip D, Grecea D, Jinga DC, Lungulescu D, Oprean CM, Stanculeanu DL, Turdean M, Dvornichenko V, Emelyanov S, Lichinitser M, Manikhas A, Sakaeva D, Shirinkin V, Stroyakovskiy D, Abulkhair O, Zekri J, Filipovic S, Kovcin V, Nedovic J, Pesic J, Vasovic S, Ng R, Bystricky B, Leskova J, Mardiak J, Mišurová E, Wagnerova M, Takač I, Demetriou GS, Dreosti L, Govender P, Jordaan JP, Veersamy P, Romero JLA, Lopez NB, Arias CC, Chacon J, Aramburo AF, Morales LAF, Garcia M, Estevez LG, Garcia-Palomo Perez A, Garcia Saenz JA, Garcia Sanchis L, Cubells LG, Cortijo LG, Santiago SG, De Aranguiz BHF, Mañas JJI, Gallego PJ, Cussac AL, Ferrandiz CL, Garrido ML, Alvarez PL, Vega JML, Del Prado PM, Jañez NM, Murillo SM, Rosales AM, Jaso LM, Fernandez IP, Martorell AP, Carrion RP, Simon SP, Alcibar AP, Lorenzo JP, Garcia VQ, Asensio TRYC, Maicas MDT, Villanueva Silva MJ, Killander F, Svensson JH, Fehr M, Hauser N, Müller A, Pagani O, Passmann-Kegel H, Popescu R, Rabaglio M, Rauch D, Schlatter C, Zaman K, Chang TW, Huang CS, Wang HC, Yu JC, Bandidwattanawong C, Maneechavakajorn J, Seetalarom K, Dejthevaporn T(S, Somwangprasert A, Vongsaisuwon M, Akbulut H, Altundag K, Arican A, Bozcuk H, Eralp Y, Idris M, Isikdogan A, Senol CH, Sevinc A, Uygun K, Yucel E, Yucel I, Yumuk F, Shparyk Y, Voitko N, Jaloudi M, Adams J, Agrawal R, Ahmed S, Alhasso A, Allerton R, Anwar S, Archer C, Ashford R, Barraclough L, Bertelli G, Bishop J, Branson T, Butt M, Chakrabarti A, Chakraborti P, Churn M, Crowley C, Davis R, Dhadda A, Eldeeb H, Fraser J, Hall J, Hickish T, Hogg M, Howe T, Joffe J, Kelleher M, Kelly S, Kendall A, Kristeleit H, Lumsden G, Macmillan C, MacPherson I, Malik Z, Mithal N, Neal A, Panwar U, Proctor A, Proctor SJ, Raj S, Rehman S, Sandri I, Scatchard K, Sherwin E, Sims E, Singer J, Smith S, Tahir S, Taylor W, Tsalic M, Verrill M, Wardley A, Waters S, Wheatley D, Wright K, Yuille F, Alonso I, Artagaveytia N, Rodriguez R, Arbona E, Garcia Y, Lion L, Marcano D, Van Thuan T. Safety and tolerability of subcutaneous trastuzumab for the adjuvant treatment of human epidermal growth factor receptor 2-positive early breast cancer: SafeHer phase III study's primary analysis of 2573 patients. Eur J Cancer 2017. [DOI: 10.1016/j.ejca.2017.05.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sjöström M, Lundstedt D, Hartman L, Holmberg E, Killander F, Kovács A, Malmström P, Niméus E, Werner Rönnerman E, Fernö M, Karlsson P. Response to Radiotherapy After Breast-Conserving Surgery in Different Breast Cancer Subtypes in the Swedish Breast Cancer Group 91 Radiotherapy Randomized Clinical Trial. J Clin Oncol 2017; 35:3222-3229. [PMID: 28759347 DOI: 10.1200/jco.2017.72.7263] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To evaluate the effect of adjuvant radiotherapy (RT) after breast conservation surgery in different breast cancer subtypes in a large, randomized clinical trial with long-term follow-up. Patients and Methods Tumor tissue was collected from 1,003 patients with node-negative, stage I and II breast cancer who were randomly assigned in the Swedish Breast Cancer Group 91 Radiotherapy trial between 1991 and 1997 to breast conservation surgery with or without RT. Systemic adjuvant treatment was sparsely used (8%). Subtyping was performed with immunohistochemistry and in situ hybridization on tissue microarrays for 958 tumors. Results RT reduced the cumulative incidence of ipsilateral breast tumor recurrence (IBTR) as a first event within 10 years for luminal A-like tumors (19% v 9%; P = .001), luminal B-like tumors (24% v 8%; P < .001), and triple-negative tumors (21% v 6%; P = .08), but not for human epidermal growth factor receptor 2-positive (luminal and nonluminal) tumors (15% v 19%; P = .6); however, evidence of an overall difference in RT effect between subtypes was weak ( P = .21). RT reduced the rate of death from breast cancer (BCD) for triple-negative tumors (hazard ratio, 0.35; P = .06), but not for other subtypes. Death from any cause was not improved by RT in any subtype. A hypothesized clinical low-risk group did not have a low risk of IBTR without RT, and RT reduced the rate of IBTR as a first event after 10 years (20% v 6%; P = .008), but had no effect on BCD or death from any cause. Conclusion Subtype was not predictive of response to RT, although, in our study, human epidermal growth factor receptor 2-positive tumors seemed to be most radioresistant, whereas triple-negative tumors had the largest effect on BCD. The effect of RT in the presumed low-risk luminal A-like tumors was excellent.
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Affiliation(s)
- Martin Sjöström
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Dan Lundstedt
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Linda Hartman
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Erik Holmberg
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Fredrika Killander
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Anikó Kovács
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Per Malmström
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Emma Niméus
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Elisabeth Werner Rönnerman
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Mårten Fernö
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Per Karlsson
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
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Villman KKA, Wickberg Å, Killander F, Lindman H, Bjöhle J, Edlund P, Tennvall-Nittby L, Bachmeier K, Carlberg M, Blomqvist C, Ahlgren J, Liljegren G. Abstract P1-10-05: Omitting radiotherapy in women ≥ 65 years with early breast cancer and favorable histopathology after breast-conserving surgery, sentinel node biopsy and adjuvant endocrine therapy is safe. Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-p1-10-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: The benefit of radiotherapy in older women with endocrine responsive early breast cancer treated with breast-conserving surgery and endocrine therapy is unclear. The aim of this study was to verify if omission of radiotherapy in a predefined cohort of patients with good prognosis early breast cancer after breast conservation is safe.
Methods: Eligibility criteria were: consecutive patients with age ≥ 65 years, breast-conserving surgery (sector resection + sentinel node biopsy), clear margins, unifocal T 1 N0, Elston grade 1 and 2, estrogen receptor-positive. After informed consent adjuvant endocrine therapy, either tamoxifen or an aromatase inhibitor, was prescribed for 5 years. Primary endpoint was ipsilateral breast tumor recurrence (IBTR). Secondary endpoints were contralateral breast cancer, recurrence-free survival (RFS) and overall survival (OS).
Results: Between 2006 and 2012, we included 603 women from 14 Swedish centers. Two patients did not fulfill the inclusion criteria and were excluded from the analysis. Median age was 71 years (range 65 to 90). At a median follow-up of 59 months (range 2 to 110) 13 IBTR (cumulative incidence at five years, 1.3% (95% CI, 0.6% to 2.7%), 4 regional recurrences (one combined with IBTR), 2 distant recurrences both without IBTR or regional recurrence and 11 contralateral breast cancers was observed. Twenty-nine patients were diagnosed with tumors of other origin. Seven of them were endometrial cancers. There were 39 deaths. Only one of the deaths (2.6%) was due to breast cancer and 11 (28.2%) were due to other cancers (2 endometrial cancers). Five-year overall survival was 93.9% (95% CI, 91.4% to 95.7%).
Conclusion: This study demonstrates, with a median follow-up of 59 months, that breast-conserving surgery and endocrine therapy without radiotherapy is a safe treatment option in women with early breast cancer and favorable histopathology aged ≥ 65 years. The risk of IBTR is comparable to the risk of contralateral breast cancer. The low rate of breast cancer deaths indicates that breast cancer mortality is of secondary importance in this subset of women.
Citation Format: Villman KKA, Wickberg Å, Killander F, Lindman H, Bjöhle J, Edlund P, Tennvall-Nittby L, Bachmeier K, Carlberg M, Blomqvist C, Ahlgren J, Liljegren G. Omitting radiotherapy in women ≥ 65 years with early breast cancer and favorable histopathology after breast-conserving surgery, sentinel node biopsy and adjuvant endocrine therapy is safe [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 P1-10-05.
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Affiliation(s)
- KKA Villman
- Örebro University Hospital, Örebro, Sweden; Skåne University Hospital, Lund University, Lund, Sweden; Akademiska Hospital, Uppsala University, Uppsala, Sweden; Karolinska Institute and University Hospital, Stockholm, Sweden; Gävle Hospital, Gävle, Sweden; Skåne University Hospital, Lund University, Malmö, Sweden; Karlstad Central Hospital, Karlstad, Sweden
| | - Å Wickberg
- Örebro University Hospital, Örebro, Sweden; Skåne University Hospital, Lund University, Lund, Sweden; Akademiska Hospital, Uppsala University, Uppsala, Sweden; Karolinska Institute and University Hospital, Stockholm, Sweden; Gävle Hospital, Gävle, Sweden; Skåne University Hospital, Lund University, Malmö, Sweden; Karlstad Central Hospital, Karlstad, Sweden
| | - F Killander
- Örebro University Hospital, Örebro, Sweden; Skåne University Hospital, Lund University, Lund, Sweden; Akademiska Hospital, Uppsala University, Uppsala, Sweden; Karolinska Institute and University Hospital, Stockholm, Sweden; Gävle Hospital, Gävle, Sweden; Skåne University Hospital, Lund University, Malmö, Sweden; Karlstad Central Hospital, Karlstad, Sweden
| | - H Lindman
- Örebro University Hospital, Örebro, Sweden; Skåne University Hospital, Lund University, Lund, Sweden; Akademiska Hospital, Uppsala University, Uppsala, Sweden; Karolinska Institute and University Hospital, Stockholm, Sweden; Gävle Hospital, Gävle, Sweden; Skåne University Hospital, Lund University, Malmö, Sweden; Karlstad Central Hospital, Karlstad, Sweden
| | - J Bjöhle
- Örebro University Hospital, Örebro, Sweden; Skåne University Hospital, Lund University, Lund, Sweden; Akademiska Hospital, Uppsala University, Uppsala, Sweden; Karolinska Institute and University Hospital, Stockholm, Sweden; Gävle Hospital, Gävle, Sweden; Skåne University Hospital, Lund University, Malmö, Sweden; Karlstad Central Hospital, Karlstad, Sweden
| | - P Edlund
- Örebro University Hospital, Örebro, Sweden; Skåne University Hospital, Lund University, Lund, Sweden; Akademiska Hospital, Uppsala University, Uppsala, Sweden; Karolinska Institute and University Hospital, Stockholm, Sweden; Gävle Hospital, Gävle, Sweden; Skåne University Hospital, Lund University, Malmö, Sweden; Karlstad Central Hospital, Karlstad, Sweden
| | - L Tennvall-Nittby
- Örebro University Hospital, Örebro, Sweden; Skåne University Hospital, Lund University, Lund, Sweden; Akademiska Hospital, Uppsala University, Uppsala, Sweden; Karolinska Institute and University Hospital, Stockholm, Sweden; Gävle Hospital, Gävle, Sweden; Skåne University Hospital, Lund University, Malmö, Sweden; Karlstad Central Hospital, Karlstad, Sweden
| | - K Bachmeier
- Örebro University Hospital, Örebro, Sweden; Skåne University Hospital, Lund University, Lund, Sweden; Akademiska Hospital, Uppsala University, Uppsala, Sweden; Karolinska Institute and University Hospital, Stockholm, Sweden; Gävle Hospital, Gävle, Sweden; Skåne University Hospital, Lund University, Malmö, Sweden; Karlstad Central Hospital, Karlstad, Sweden
| | - M Carlberg
- Örebro University Hospital, Örebro, Sweden; Skåne University Hospital, Lund University, Lund, Sweden; Akademiska Hospital, Uppsala University, Uppsala, Sweden; Karolinska Institute and University Hospital, Stockholm, Sweden; Gävle Hospital, Gävle, Sweden; Skåne University Hospital, Lund University, Malmö, Sweden; Karlstad Central Hospital, Karlstad, Sweden
| | - C Blomqvist
- Örebro University Hospital, Örebro, Sweden; Skåne University Hospital, Lund University, Lund, Sweden; Akademiska Hospital, Uppsala University, Uppsala, Sweden; Karolinska Institute and University Hospital, Stockholm, Sweden; Gävle Hospital, Gävle, Sweden; Skåne University Hospital, Lund University, Malmö, Sweden; Karlstad Central Hospital, Karlstad, Sweden
| | - J Ahlgren
- Örebro University Hospital, Örebro, Sweden; Skåne University Hospital, Lund University, Lund, Sweden; Akademiska Hospital, Uppsala University, Uppsala, Sweden; Karolinska Institute and University Hospital, Stockholm, Sweden; Gävle Hospital, Gävle, Sweden; Skåne University Hospital, Lund University, Malmö, Sweden; Karlstad Central Hospital, Karlstad, Sweden
| | - G Liljegren
- Örebro University Hospital, Örebro, Sweden; Skåne University Hospital, Lund University, Lund, Sweden; Akademiska Hospital, Uppsala University, Uppsala, Sweden; Karolinska Institute and University Hospital, Stockholm, Sweden; Gävle Hospital, Gävle, Sweden; Skåne University Hospital, Lund University, Malmö, Sweden; Karlstad Central Hospital, Karlstad, Sweden
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Killander F, Karlsson P, Anderson H, Mattsson J, Holmberg E, Lundstedt D, Holmberg L, Malmström P. No breast cancer subgroup can be spared postoperative radiotherapy after breast-conserving surgery. Fifteen-year results from the Swedish Breast Cancer Group randomised trial, SweBCG 91 RT. Eur J Cancer 2016; 67:57-65. [PMID: 27614164 DOI: 10.1016/j.ejca.2016.08.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 07/29/2016] [Accepted: 08/01/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Breast-conserving surgery (BCS) followed by radiotherapy (RT) is an established treatment for women with T1-2N0 breast cancers. Since subgroups of patients have low ipsilateral breast tumour recurrence (IBTR) rates, it is important to study whether RT is necessary for all patients. PATIENTS AND METHODS A total of 1187 women with primary T1-2N0M0 breast cancer were randomised, after standardised sector resection, to postoperative whole breast RT or no local treatment. Adjuvant systemic therapy was offered to patients with stage II cancers. Patients were followed with clinical examinations and annual mammography for 10 years and thereafter referred to the Swedish mammography screening program. RESULTS After 15 years of follow-up, a higher cumulative incidence of IBTR was observed in control patients, 23.9%, versus irradiated patients, 11.5%, P<0.001. Recurrence-free survival was inferior, 51.7% versus 60.4%, P=0.0013. The main effect of RT was seen during the first 5 years. However, overall survival was not significantly lower 68.4% versus 71.1%, P=0.68, nor was breast cancer-specific mortality significantly higher. CONCLUSIONS RT after BCS significantly reduced the incidence of IBTR at 15 years of follow-up. We were unable to identify subgroups which could be spared RT. Breast cancer mortality was not significantly reduced after RT. Good predictive markers for radiation sensitivity and improved adjuvant systemic therapy are needed to omit RT after BCS.
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Affiliation(s)
- F Killander
- Department of Clinical Sciences, Oncology, Lund University, Lund, Sweden; Skåne Department of Oncology, Skåne University Hospital, Lund, Sweden.
| | - P Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Sweden
| | - H Anderson
- Department of Clinical Sciences, Cancer Epidemiology, Lund, Sweden
| | - J Mattsson
- Department of Surgery, Sahlgrenska University Hospital, Göteborg, Sweden
| | - E Holmberg
- Regional Oncologic Centre, Sahlgrenska University Hospital, Göteborg, Sweden
| | - D Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Sweden
| | - L Holmberg
- Regional Oncologic Centre, Uppsala University Hospital, Uppsala, Sweden; King's College London, Faculty of Life Sciences and Medicine, Division of Cancer Studies, London, UK
| | - P Malmström
- Department of Clinical Sciences, Oncology, Lund University, Lund, Sweden; Skåne Department of Oncology, Skåne University Hospital, Lund, Sweden
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Killander F, Anderson H, Kjellén E, Malmström P. Increased cardio and cerebrovascular mortality in breast cancer patients treated with postmastectomy radiotherapy--25 year follow-up of a randomised trial from the South Sweden Breast Cancer Group. Eur J Cancer 2014; 50:2201-10. [PMID: 24951164 DOI: 10.1016/j.ejca.2014.04.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 03/27/2014] [Accepted: 04/23/2014] [Indexed: 11/15/2022]
Abstract
AIM OF THE STUDY To analyse late morbidity and mortality in pre and post-menopausal breast cancer patients treated with postmastectomy radiotherapy, with emphasis on side-effects from the heart, cerebrovascular and respiratory systems. METHODS Long term follow-up of two randomised, clinical trials with 1100 patients was carried out. Pre-menopausal women were allocated to radiotherapy (RT), RT+oral cyclophosphamide (RT+C) or cyclophosphamide only (C). Post-menopausal women were allocated to RT, RT+Tamoxifen for one year (RT+Tam) or tamoxifen only (Tam). Information on admission to hospital, mortality and causes of death was obtained from national registers. RESULTS After 25 years, adding RT to cyclophosphamide in pre-menopausal women raised the mortality from heart disease from zero to 0.8% (p=0.04). In post-menopausal women, adding RT to Tam raised the mortality from heart disease from 10.5% to 18.4% (p=0.005). In post-menopausal women mortality due to cerebrovascular disease increased from 3.4% to 8.7% by adding RT to Tam (p=0.015). The differences were not evident until in the second decade of follow-up. In spite of differences in specific causes of death, there were no significant differences between the treatment arms concerning morbidity or overall mortality. CONCLUSION Postmastectomy radiotherapy to the chest wall and loco-regional lymph nodes including the parasternal lymph nodes as delivered in the end of the seventies did not reduce overall mortality, but gave a significantly increased risk of death from heart and cerebrovascular disease, which appeared during the second decade after radiotherapy.
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Affiliation(s)
- Fredrika Killander
- Skåne Department of Oncology, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences, Division of Oncology, Lund University, Lund, Sweden.
| | - Harald Anderson
- Department of Cancer Epidemiology, Lund University, Lund, Sweden
| | - Elisabeth Kjellén
- Skåne Department of Oncology, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences, Division of Oncology, Lund University, Lund, Sweden
| | - Per Malmström
- Skåne Department of Oncology, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences, Division of Oncology, Lund University, Lund, Sweden
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Johansson I, Killander F, Linderholm B, Hedenfalk I. Molecular profiling of male breast cancer - lost in translation? Int J Biochem Cell Biol 2014; 53:526-35. [PMID: 24842109 DOI: 10.1016/j.biocel.2014.05.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 05/07/2014] [Accepted: 05/09/2014] [Indexed: 02/06/2023]
Abstract
Breast cancer is the most common cancer form in women and it has been extensively studied on the molecular level. Male breast cancer (MBC), on the other hand, is rare and has not been thoroughly investigated in terms of transcriptional profiles or genomic aberrations. Most of our understanding of MBC has therefore been extrapolated from knowledge of female breast cancer. Although differences in addition to similarities with female breast cancer have been reported, the same prognostic and predictive markers are used to determine optimal management strategies for both men and women diagnosed with breast cancer. This review is focused on prognosis for MBC patients, prognostic and predictive factors and molecular subgrouping; comparisons are made with female breast cancer. Information was collected from relevant literature on both male and female breast cancer from the MEDLINE database between 1992 and 2014. MBC is a heterogeneous disease, and on the molecular level many differences compared to female breast cancer have recently been revealed. Two distinct subgroups of MBC, luminal M1 and luminal M2, have been identified which differ from the well-established intrinsic subtypes of breast cancer in women. These novel subgroups of breast cancer therefore appear unique to MBC. Furthermore, several studies report inferior survival for men diagnosed with breast cancer compared to women. New promising prognostic biomarkers for MBC (e.g. NAT1) deserving further attention are reviewed. Further prospective studies aimed at validating the novel subgroups and recently proposed biomarkers for MBC are warranted to provide the basis for optimal patient management in this era of personalized medicine. This article is part of a Directed Issue entitled: Rare Cancers.
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Affiliation(s)
- Ida Johansson
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University Cancer Center, Lund, Sweden; CREATE Health Strategic Center for Translational Cancer Research, Lund University, Lund, Sweden
| | - Fredrika Killander
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University Cancer Center, Lund, Sweden; Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - Barbro Linderholm
- Department of Oncology, Sahlgrenska Academy and University Hospital, Gothenburg, Sweden; Cancer Center Karolinska, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Hedenfalk
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University Cancer Center, Lund, Sweden; CREATE Health Strategic Center for Translational Cancer Research, Lund University, Lund, Sweden.
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Magnusson M, Höglund P, Johansson K, Jönsson C, Killander F, Malmström P, Weddig A, Kjellén E. Pentoxifylline and vitamin E treatment for prevention of radiation-induced side-effects in women with breast cancer: A phase two, double-blind, placebo-controlled randomised clinical trial (Ptx-5). Eur J Cancer 2009; 45:2488-95. [PMID: 19540105 DOI: 10.1016/j.ejca.2009.05.015] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Revised: 04/28/2009] [Accepted: 05/11/2009] [Indexed: 02/07/2023]
Affiliation(s)
- Marie Magnusson
- Department of Clinical Pharmacology, Lund University Hospital, Lund SE 221 85, Sweden
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Killander F, Anderson H, Möller T, Rydén S, Malmström P. No positive effect of postmastectomy radiotherapy on mortality at 20 years in pre menopausal women with stage II breast cancer also treated with adjuvant oral cyclophopsphamide. South Sweden Breast Cancer Group, trial SBII:I. Cancer Res 2009. [DOI: 10.1158/0008-5472.sabcs-5128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Abstract #5128
Purpose: To study long term loco-regional recurrence rate and survival after postmastectomy radiotherapy in combination with oral cyclophosphamide in premenopausal women with stage II breast cancer.
 Study design: A three-armed randomised, multicenter, phase III trial comparing 1) Radiotherapy (RT) 2) RT+ oral cyclophosphamide for one year (RT+C) and 3) cyclophosphamide only (C).
 Radiotherapy was administered with 48 Gy in 20 fractions to chest wall and locoregional lymph nodes (Arwidi Å, Acta Oncol Scand 18:273-281, 1979). Cyclophosphamide was prescribed as 12 courses of 130 mg/m2 od for14 days every 4 weeks.
 Patients and methods: 367 patients from 15 departments in Southern Sweden, representing 80% of all eligible patients, were included in the trial between 1978-1983; n=124 (RT), n=118 (RT+C), n=125 (C). Median age was 47 years, median tumour size was 25 mm, and 33 % of the patients were lymph node negative. Median follow up for survival was 24 years and 21 years for other events.
 Results: RT reduced the risk at twenty years for locoregional recurrence in C treated patients with 75 %, 13.9 vs 3.5 %. The risk reduction was highly significant in both N0 and N+ patients. RT did not decrease systemic disease or mortality, see table 1. Chemotherapy did not decrease mortality when added to radiotherapy, though difficult to evaluate because of lack of information on delivered doses in many cases.
 
 Conclusion: Postmastectomy radiotherapy reduces loco regional recurrences in this premenopausal population, but no effect was seen on mortality at 20 years. Possible explanations are 1) low number of loco regional recurrences and superior survival in comparison to other trials investigating postmastectomy radiotherapy, which might have modified the effect of RT on survival, 2) too low intensity of adjuvant, single agent chemotherapy, and 3) chance, since relatively small study with little power.
Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5128.
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Affiliation(s)
- F Killander
- 1 Department of Oncology, Lund University Hospital, Lund, Sweden
| | - H Anderson
- 2 Department of Epidemiology, Lund University, Lund, Sweden
| | - T Möller
- 2 Department of Epidemiology, Lund University, Lund, Sweden
| | - S Rydén
- 3 Department of Health and Medical Service, Region Skåne, Lund, Sweden
| | - P Malmström
- 1 Department of Oncology, Lund University Hospital, Lund, Sweden
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Killander F, Anderson H, Rydén S, Möller T, Aspegren K, Ceberg J, Danewid C, Malmström P. Radiotherapy and tamoxifen after mastectomy in postmenopausal women – 20 year follow-up of the South Sweden Breast Cancer group randomised trial SSBCG II:I. Eur J Cancer 2007; 43:2100-8. [PMID: 17644330 DOI: 10.1016/j.ejca.2007.05.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2007] [Accepted: 05/29/2007] [Indexed: 11/17/2022]
Abstract
AIMS To evaluate long-term effects of radiotherapy and tamoxifen after mastectomy on recurrence and survival in stage II breast cancer. METHODS A randomised phase III study with three treatment alternatives. (1) Radiotherapy 50 Gy/25 fractions to chest wall and regional lymph nodes (RT). (2) Radiotherapy and tamoxifen 30 mg/day for one year (RT+tam) and 3. Tamoxifen (tam). RESULTS 724 postmenopausal women were included between 1978 and 1985 and the trial was close to population based. Follow-up for survival was 23 years. Locoregional recurrences were reduced from 18.5% in the tam arm to 5.3% in the RT+tam arm. Overall mortality at 20 years was 71% in the RT arm, 68% in the RT+tam arm and 62% in the tam arm. The difference between RT+tam and tam was not significant except in the receptor positive subgroup in favour of non-irradiated patients (p=0.047). The cumulative incidence of systemic disease at 20 years was lower in the RT+Tam arm than in the RT arm, 40% versus 50% (p=0.047). CONCLUSION Postmastectomy radiotherapy significantly reduced loco-regional recurrences, but overall survival was not improved. At 20 years, a lower mortality was recorded for non-irradiated patients treated with tam.
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Pero RW, Olsson H, Killander F, Troll W. Elevation of ADP-ribosylation as an indicator of mononuclear leucocyte responsiveness in breast cancer patients treated with tamoxifen. Eur J Cancer 1992; 28A:1803-6. [PMID: 1389513 DOI: 10.1016/0959-8049(92)90007-o] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
82 women who had had surgery for removal of breast cancer were randomised during the primary care period before initiation of any chemotherapy or radiotherapy into two groups: no drug treatment (n = 40) and 20 mg tamoxifen per day for 2 years (n = 42). Mononuclear leucocyte (MNL) fractions from blood samples were collected during the first 368 days of the study and ADP-ribosylation was quantified. Tamoxifen treatment resulted in a dose-duration increase in ADP-ribosylation. This was true even after adjustment for covariates such as age, smoking habits, oestrogen use, menstruation and tumour size. These data suggest that part of the antitumour effects of tamoxifen treatment in vivo relates to an enhanced immune cell responsiveness, as indicated by the increased MNL ADP-ribosylation.
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Affiliation(s)
- R W Pero
- Department of Molecular Ecogenetics, University of Lund, Wallenberg Laboratory, Sweden
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