Implications of the 21-gene recurrence score assay (Oncotype DX) on adjuvant treatment decisions in ER-positive early-stage breast cancer patients: experience of Kuwait Cancer Control Center

BACKGROUND

The Oncotype DX is a quantitative assay of the expression of 16 tumor-related genes and 5 reference genes that predicts the potential of adjuvant chemotherapy benefit in estrogen receptor (ER)-positive early breast cancer patients. The study aims to evaluate the impact of Oncotype DX as a tool for adjuvant treatment decision of ER-positive, HER2-negative, N0/N1 early-stage breast cancer patients and to determine which clinicopathological criteria derived the greatest advantage.

RESULTS

A hundred patients at a median age of 50 years were included. TNM stage distribution was 34, 63, and 3 patients for stages I, II, and IIIA respectively. Fifty-four patients had luminal A and 46 had luminal B tumors. The recurrence score (RS) results were low, intermediate, and high risk in 54, 34, and 12 patients respectively. Before the test results, adjuvant chemoendocrine therapy (CET) was recommended for 46 patients while 54 were advised for endocrine therapy (ET). After getting the test results, 25 patients received CET (1, 12, and12 patients in the low-, intermediate-, and high-risk groups respectively) and 75 received ET. Treatment change was documented in 37 patients (8 patients from ET to CET and 29 from CET to ET; p = 0.001, McNemar test). Treatment change was significant among patients ≤ 50 years, luminal B tumors, stage II and IIIA disease, and node-positive disease.

CONCLUSION

Oncotype DX testing resulted in significant changes in the adjuvant treatment decisions in ER-positive, HER2-negative early breast cancer particularly in the case of young, luminal B, N1, and stage II-IIIA disease.

Colon Cancer in Patients below Age of 50 Years: Kuwait Cancer Control Center Experience

BACKGROUND

This study was undertaken to analyze and evaluate the clinico-pathological profile and the outcome of young patients diagnosed with colon cancer.

PATIENTS AND METHODS

Patients diagnosed with adenocarcinoma of the colon at or below the age of 50 years from January 2000 to December 2007 in Kuwait were analyzed. This study retrieved 130 patients diagnosed = 50 years, representing 22% of colon cancer patients in this period, 67 females and 63 males. Patients = 40 years were 48 while those 41-50 years were 82. Median follow-up was 61 months.

RESULTS

According to the TNM system, 82% patients had T3 and T4 disease, 55% had node negative disease and 15% had distant metastasis at presentation. All patients except three underwent surgery. Chemotherapy was given in 82% of patients either for adjuvant or palliative intent. The 5-year overall survival (OS) and progression free survival (PFS) were 78% and 75% respectively. Survival was significantly affected by the disease stage and grade. The OS was 96%, 83%, 6% for stage I and II, III and IV respectively (p<0.001). OS was 91% for grade 1 and 2 tumors vs. 60% for grade 3 tumors (p=0.007). Patients who presented = 40 years had relatively more grade 3 (19% vs. 7%) compared to 41-50-years age group.

CONCLUSIONS

Colonic adenocarcinoma is frequently diagnosed below the age of 50 in our population. Younger age (=40 years) seems to present more with high grade tumors. Clinicians should consider full colonoscopic evaluation while investigating symptomatic young patients.

Second Primary Tumors associated with Breast Cancer: Kuwait Cancer Control Center Experience

OBJECTIVES

To review the clinico-epidemiologic characteristics of patients who presented with two or more primary cancers, one of which was breast cancer (BC) and to develop a follow-up program for the high risk patients.

PATIENTS AND METHODS

Patients who were diagnosed with BC and one or more non breast cancer (NBC) were retrospectively reviewed. Medical files were retrieved and epidemiological as well as clinical data were analyzed.

RESULTS

Sixty-two patients were retrieved. BC was the first primary in 26 patients while it was the second in 36 patients. Two were males and 60 were females. The median age was 48 years and the median follow-up was 11.5 years. The median interval between the 1st and 2nd primary was 6 years. The most commonly associated NBCs were colon and thyroid cancers, each accounts for 24% of cases followed by endometrial cancer, 18%; Hodgkin's disease, 6.5%; renal and ovarian neoplasm and NHL, 5% each. Others included prostate, lung, cervical and gastric cancers, soft tissue sarcoma and osteosarcoma. Thyroid cancer was more common as first cancer while endometrial cancer was more as second cancer. All patients who developed BC following Hodgkin's disease had received chest irradiation. Seven patients developed 3rd primary (4 lung cancers, 2 NHL, and 1 AML).

CONCLUSION

Patients who were diagnosed with BC should be screened for colon and endometrial cancer. Similarly, patients received chest irradiation at young age, and those diagnosed with thyroid or colon cancer should be screened for BC. Protocol of surveillance needs to be defined. Genetic counseling should be offered to individuals who have experienced multiple primary cancers particularly those with family history and young age of onset.

Metaplastic breast carcinoma: Analysis of 31 cases from a single institute

PURPOSE

Metaplastic carcinoma of the breast (MBC) accounts for less than 1% of all mammary tumors. This study aimed at revision of the clinico-pathological features, treatment strategy and outcome for MBC patients presented to the Kuwait Cancer Control Center to define the clinical behavior and prognostic factors of these neoplasms in our population.

PATIENT AND METHODS

Thirty-one patients were retrieved from our surgical pathology registry between January 2005 and December 2014. Medical records were revised regarding the clinico-pathological features and treatment outcome.

RESULTS

MBC represented 1% of our breast cancer patients. The median age was 50years (32-70years). Two patients presented with metastatic disease. Mastectomy was done for 24 patients and 7 had conservative surgery. The median tumor size at the time of surgery was 5.5cm (1.5-12cm). Axillary nodes were negative in 21 patients (N0), 5 patients were N1, 4 patients were N2 and one Nx. Three histological subtypes were presented: carcinosarcoma (7 cases), squamous cell carcinoma/IDC with squamous differentiation (15 cases), high grade IDC with metaplastic differentiation (9 cases). Immunohistochemically, 26 were negative hormone receptors and all were negative for Her2/neu overexpression. Chemotherapy was used in 28 patients, and adjuvant radiotherapy in 24 patients. The median follow-up was 47months (7-126months), six patients lost follow-up. The 5-year OS was 69% and 5-year PFS was 50%.

CONCLUSION

MBC is a rare entity among breast carcinoma in Kuwait. Most of the cases present with poor prognostic indicators and often show lack of expression of ER, PR and Her2/neu.

Significance of Magnetic Resonance Imaging-Assessed Tumor Response for Locally Advanced Rectal Cancer Treated With Preoperative Long-Course Chemoradiation

Purpose

To study the predictive and prognostic value of magnetic resonance imaging (MRI)–assessed tumor response after long-course neoadjuvant therapy for locally advanced rectal cancer.

Methods

This study included 79 patients who had T3 or T4 and/or N+ rectal cancer treated with long-course neoadjuvant chemoradiation. MRI-assessed tumor regression grade (mrTRG) was assessed in 64 patients. MRIs were reviewed by the study radiologist. Surgical and pathologic reports for those who underwent surgery were reviewed. Disease-free survival (DFS) was estimated. Progression during therapy, local relapse, metastasis, and death resulting from the tumor were classified as events. Statistical significance was calculated.

Results

In 11 patients, the tumor completely disappeared on MRI; that is, it had an mrTRG of 1. All but one patient, who chose deferred surgery, had a complete pathologic response (pCR), with a positive predictive value of nearly 100%. Of the 20 patients who had an mrTRG of 2 on MRI, six had a pCR. mrTRG 3, mrTRG 4, and mrTRG 5 were detected in 24, six, and three patients, respectively, of whom only one patient had a pCR. The 2-year DFS was 77%. The mrTRG was significant for DFS. The 2-year DFS was 88% for patients with a good response versus 66% for those with a poor response (P = .046).

Conclusion

MRI-assessed complete tumor response was strongly correlated with pCR and, therefore, can be used as a surrogate marker to predict absence of viable tumor cells. Our results can be used to implement use of mrTRGs in larger prospective correlative studies as a tool to select patients for whom deferred surgery may be appropriate. Also, those with a poor response may be offered further treatment options before definitive surgery.

Is young age a poor prognostic factor in triple-negative breast cancer patients? Analysis of 363 patients from single institution registry

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Background: Young age is a known independent poor prognostic factor for breast cancer. Few data exist about validating such prognostic factor in triple negative subtype of breast cancer. In this study, we evaluate the prognostic value of young age presentation in triple negative breast cancer (TNBC) patients who were diagnosed in Kuwait Cancer Control Center. Methods: This is a retrospective analysis of 363 patients diagnosed with TNBC between July 1999 and June 2009. Of these, 27% were diagnosed at or below the age of 40. Chi-square test was used to correlate the age with other prognostic factors. Survival measurements were estimated using Kaplan-Meier analysis. Statistical significance was calculated using the log-rank test. Results: There was no correlation between young age at presentation and other prognostic factors including grade, T stage, lymph node status, lymphovascular invasion, and Ki67 positivity. Similarly, young age was not statistically associated with poorer 5-years overall survival (78% for patients < 40 years compared to 72% for those > 40 years; p = 0.13), disease free survival (66% vs. 61%; p = 0.5) or locoregional recurrence free survival (81% vs. 83%; p = 0.7). Conclusions: Young age does not seem to negatively impact the survival of TNBC patients nor associated with poor prognostic factors in our study population. Further studies are needed to define new prognostic factors, e.g. molecular markers, in this subtype of patients rather than the conventional clinicopathologic prognostic factors.

Intensive alternating 6-drug chemotherapy for high-risk nonmetastatic rhabdomyosarcoma in children and adolescents: Impact on survival

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Background: Both 5-year overall survival (OS) and event free survival (EFS) for pediatric rhabdomyosarcoma (RMS) has increased in the last 3 decades through multimodality, risk-adapted management. The reported EFS for high risk RMS in children treated at the NCI in Egypt during the 1990s was 50%. Using an intensive 6 drug alternating chemotherapy regimen in addition to local control measures was our aim to improve the outcome for this group of patients. Methods: Forty-six previously untreated patients, younger than 21 years of age, with localized high risk RMS received this regimen. High risk criteria included: (1) Localized tumors (T1) biopsied or incompletely resected, ortumors extending beyond the tissue or organ of origin (T2) completely or incompletely resected at any site (excluding orbit, uterus, vagina, and paratestis); (2)All node positive patients with primary tumor at any site; and (3) All RMS with alveolar histology at any site. Chemotherapy regimen comprised 27 weeks of alternating 6 drugs (carboplatin, doxorubicin hydrochloride, ifosfamide, actinomycin D, etoposide, vincristine). Local therapy (surgery, radiotherapy, or both) was offered at week 9. Results: Forty-six patients meeting high-risk criteria were recruited from September 2000 to November 2005. Median follow-up of survivors was 62 months. The 5-year OS and EFS for the whole group was 64% ± 10% and 47% ± 8% respectively. The EFS was significantly affected by: the size of the tumor (≤5 cm vs. > 5 cm, p= 0.03), SIOP UICC clinical stage (p = 0.004), IRS stage (p = 0.01), lymph node status (p = 0.02), surgery vs. incisional biopsy (p=0.01) and overall duration of time in which therapy was delivered (p = 0.04). There was significant toxicity, mainly hematologic, but only one treatment related fatality. Conclusions: The use of intensified alternating 6-drug CT did not improve the EFS compared with historical control although it was feasible to be delivered safely in a variety of outpatient settings. Surgical resection of the tumor is essential. Delivering therapy in a timely fashion appears to impact outcome and future investigations will focus on impediments to administering chemotherapy as scheduled.