Prognostic value of histopathologic traits independent of stromal tumor-infiltrating lymphocyte levels in chemotherapy-naïve patients with triple-negative breast cancer

BACKGROUND

In the absence of prognostic biomarkers, most patients with early-stage triple-negative breast cancer (eTNBC) are treated with combination chemotherapy. The identification of biomarkers to select patients for whom treatment de-escalation or escalation could be considered remains an unmet need. We evaluated the prognostic value of histopathologic traits in a unique cohort of young, (neo)adjuvant chemotherapy-naïve patients with early-stage (stage I or II), node-negative TNBC and long-term follow-up, in relation to stromal tumor-infiltrating lymphocytes (sTILs) for which the prognostic value was recently reported.

MATERIALS AND METHODS

We studied all 485 patients with node-negative eTNBC from the population-based PARADIGM cohort which selected women aged <40 years diagnosed between 1989 and 2000. None of the patients had received (neo)adjuvant chemotherapy according to standard practice at the time. Associations between histopathologic traits and breast cancer-specific survival (BCSS) were analyzed with Cox proportional hazard models.

RESULTS

With a median follow-up of 20.0 years, an independent prognostic value for BCSS was observed for lymphovascular invasion (LVI) [adjusted (adj.) hazard ratio (HR) 2.35, 95% confidence interval (CI) 1.49-3.69], fibrotic focus (adj. HR 1.61, 95% CI 1.09-2.37) and sTILs (per 10% increment adj. HR 0.75, 95% CI 0.69-0.82). In the sTILs <30% subgroup, the presence of LVI resulted in a higher cumulative incidence of breast cancer death (at 20 years, 58%; 95% CI 41% to 72%) compared with when LVI was absent (at 20 years, 32%; 95% CI 26% to 39%). In the ≥75% sTILs subgroup, the presence of LVI might be associated with poor survival (HR 11.45, 95% CI 0.71-182.36, two deaths). We confirm the lack of prognostic value of androgen receptor expression and human epidermal growth factor receptor 2 -low status.

CONCLUSIONS

sTILs, LVI and fibrotic focus provide independent prognostic information in young women with node-negative eTNBC. Our results are of importance for the selection of patients for de-escalation and escalation trials.

Causality and functional relevance of BRCA1 and BRCA2 pathogenic variants in non-high-grade serous ovarian carcinomas

The identification of causal BRCA1/2 pathogenic variants (PVs) in epithelial ovarian carcinoma (EOC) aids the selection of patients for genetic counselling and treatment decision-making. Current recommendations therefore stress sequencing of all EOCs, regardless of histotype. Although it is recognised that BRCA1/2 PVs cluster in high-grade serous ovarian carcinomas (HGSOC), this view is largely unsubstantiated by detailed analysis. Here, we aimed to analyse the results of BRCA1/2 tumour sequencing in a centrally revised, consecutive, prospective series including all EOC histotypes. Sequencing of n = 946 EOCs revealed BRCA1/2 PVs in 125 samples (13%), only eight of which were found in non-HGSOC histotypes. Specifically, BRCA1/2 PVs were identified in high-grade endometrioid (3/20; 15%), low-grade endometrioid (1/40; 2.5%), low-grade serous (3/67; 4.5%), and clear cell (1/64; 1.6%) EOCs. No PVs were identified in any mucinous ovarian carcinomas tested. By re-evaluation and using loss of heterozygosity and homologous recombination deficiency analyses, we then assessed: (1) whether the eight 'anomalous' cases were potentially histologically misclassified and (2) whether the identified variants were likely causal in carcinogenesis. The first 'anomalous' non-HGSOC with a BRCA1/2 PV proved to be a misdiagnosed HGSOC. Next, germline BRCA2 variants, found in two p53-abnormal high-grade endometrioid tumours, showed substantial evidence supporting causality. One additional, likely causal variant, found in a p53-wildtype low-grade serous ovarian carcinoma, was of somatic origin. The remaining cases showed retention of the BRCA1/2 wildtype allele, suggestive of non-causal secondary passenger variants. We conclude that likely causal BRCA1/2 variants are present in high-grade endometrioid tumours but are absent from the other EOC histotypes tested. Although the findings require validation, these results seem to justify a transition from universal to histotype-directed sequencing. Furthermore, in-depth functional analysis of tumours harbouring BRCA1/2 variants combined with detailed revision of cancer histotypes can serve as a model in other BRCA1/2-related cancers. © 2023 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

BluePrint molecular subtypes predict response to neoadjuvant pertuzumab in HER2-positive breast cancer

BACKGROUND

The introduction of pertuzumab has greatly improved pathological complete response (pCR) rates in HER2-positive breast cancer, yet effects on long-term survival have been limited and it is uncertain which patients derive most benefit. In this study, we determine the prognostic value of BluePrint subtyping in HER2-positive breast cancer. Additionally, we evaluate its use as a biomarker for predicting response to trastuzumab-containing neoadjuvant chemotherapy with or without pertuzumab.

METHODS

From a cohort of patients with stage II-III HER2-positive breast cancer who were treated with neoadjuvant chemotherapy and trastuzumab with or without pertuzumab, 836 patients were selected for microarray gene expression analysis, followed by readout of BluePrint standard (HER2, Basal and Luminal) and dual subtypes (HER2-single, Basal-single, Luminal-single, HER2-Basal, Luminal-HER2, Luminal-HER2-Basal). The associations between subtypes and pathological complete response (pCR), overall survival (OS) and breast cancer-specific survival (BCSS) were assessed, and pertuzumab benefit was evaluated within the BluePrint subgroups.

RESULTS

BluePrint results were available for 719 patients. In patients with HER2-type tumors, the pCR rate was 71.9% in patients who received pertuzumab versus 43.5% in patients who did not (adjusted Odds Ratio 3.43, 95% CI 2.36-4.96). Additionally, a significantly decreased hazard was observed for both OS (adjusted hazard ratio [aHR] 0.45, 95% CI 0.25-0.80) and BCSS (aHR 0.46, 95% CI 0.24-0.86) with pertuzumab treatment. Findings were similar in the HER2-single subgroup. No significant benefit of pertuzumab was seen in other subtypes.

CONCLUSIONS

In patients with HER2-type or HER2-single-type tumors, pertuzumab significantly improved the pCR rate and decreased the risk of breast cancer mortality, which was not observed in other subtypes. BluePrint subtyping may be valuable in future studies to identify patients that are likely to be highly sensitive to HER2-targeting agents.

Validation of the 70-gene signature test (MammaPrint) to identify patients with breast cancer aged ≥ 70 years with ultralow risk of distant recurrence: A population-based cohort study

INTRODUCTION

When risk estimation in older patients with hormone receptor positive breast cancer (HR + BC) is based on the same factors as in younger patients, age-related factors regarding recurrence risk and other-cause mortality are not considered. Genomic risk assessment could help identify patients with ultralow risk BC who can forgo adjuvant treatment. However, assessment tools should be validated specifically for older patients. This study aims to determine whether the 70-gene signature test (MammaPrint) can identify patients with HR + BC aged ≥70 years with ultralow risk for distant recurrence.

MATERIALS AND METHODS

Inclusion criteria: ≥70 years; invasive HR + BC; T1-2N0-3M0.

EXCLUSION CRITERIA

HER2 + BC; neoadjuvant therapy. MammaPrint assays were performed following standardized protocols. Clinical risk was determined with St. Gallen risk classification. Primary endpoint was 10-year cumulative incidence rate of distant recurrence in relation to genomic risk. Subdistribution hazard ratios (sHR) were estimated from Fine and Gray analyses. Multivariate analyses were adjusted for adjuvant endocrine therapy and clinical risk.

RESULTS

This study included 418 patients, median age 78 years (interquartile range [IQR] 73-83). Sixty percent of patients were treated with endocrine therapy. MammaPrint classified 50 patients as MammaPrint-ultralow, 224 patients as MammaPrint-low, and 144 patients as MammaPrint-high risk. Regarding clinical risk, 50 patients were classified low, 237 intermediate, and 131 high. Discordance was observed between clinical and genomic risk in 14 MammaPrint-ultralow risk patients who were high clinical risk, and 84 patients who were MammaPrint-high risk, but low or intermediate clinical risk. Median follow-up was 9.2 years (IQR 7.9-10.5). The 10-year distant recurrence rate was 17% (95% confidence interval [CI] 11-23) in MammaPrint-high risk patients, 8% (4-12) in MammaPrint-low (HR 0.46; 95%CI 0.25-0.84), and 2% (0-6) in MammaPrint-ultralow risk patients (HR 0.11; 95%CI 0.02-0.81). After adjustment for clinical risk and endocrine therapy, MammaPrint-high risk patients still had significantly higher 10-year distant recurrence rate than MammaPrint-low (sHR 0.49; 95%CI 0.26-0.90) and MammaPrint-ultralow patients (sHR 0.12; 95%CI 0.02-0.85). Of the 14 MammaPrint-ultralow, high clinical risk patients none developed a distant recurrence.

DISCUSSION

These data add to the evidence validating MammaPrint's ultralow risk threshold. Even in high clinical risk patients, MammaPrint-ultralow risk patients remained recurrence-free ten years after diagnosis. These findings justify future studies into using MammaPrint to individualize adjuvant treatment in older patients.

Beyond the snapshot: optimizing prognostication and prediction by moving from fixed to functional multidimensional cancer pathology

The role of pathology in patient management has evolved over time from the retrospective review of cells, tissue, and disease (‘what happened’) to a prospective outlook (‘what will happen’). Examination of a static, two‐dimensional hematoxylin and eosin (H&E)‐stained tissue slide has traditionally been the pathologist's primary task, but novel ancillary techniques enabled by technological breakthroughs have supported pathologists in their increasing ability to predict disease status and behaviour. Nevertheless, the informational limits of 2D, fixed tissue are now being reached and technological innovation is urgently needed to ensure that our understanding of disease entities continues to support improved individualized treatment options. Here we review pioneering work currently underway in the field of cancer pathology that has the potential to capture information beyond the current basic snapshot. A selection of exciting new technologies is discussed that promise to facilitate integration of the functional and multidimensional (space and time) information needed to optimize the prognostic and predictive value of cancer pathology. Learning how to analyse, interpret, and apply the wealth of data acquired by these new approaches will challenge the knowledge and skills of the pathology community. © 2022 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Source apportionment to support air quality planning: Strengths and weaknesses of existing approaches

Information on the origin of pollution constitutes an essential step of air quality management as it helps identifying measures to control air pollution. In this work, we review the most widely used source-apportionment methods for air quality management. Using theoretical and real-case datasets we study the differences among these methods and explain why they result in very different conclusions to support air quality planning. These differences are a consequence of the intrinsic assumptions that underpin the different methodologies and determine/limit their range of applicability. We show that ignoring their underlying assumptions is a risk for efficient/successful air quality management as these methods are sometimes used beyond their scope and range of applicability. The simplest approach based on increments (incremental approach) is often not suitable to support air quality planning. Contributions obtained through mass-transfer methods (receptor models or tagging approaches built in air quality models) are appropriate to support planning but only for specific pollutants. Impacts obtained via "brute-force" methods are the best suited but it is important to assess carefully their application range to make sure they reproduce correctly the prevailing chemical regimes.

Adjuvant dose-dense doxorubicin-cyclophosphamide versus docetaxel-doxorubicin-cyclophosphamide for high-risk breast cancer: First results of the randomised MATADOR trial (BOOG 2004-04)

BACKGROUND

Dose-dense administration of chemotherapy and the addition of taxanes to anthracycline-based adjuvant chemotherapy have improved breast cancer survival substantially. However, clinical trials directly comparing the additive value of taxanes with dose-dense anthracycline-based chemotherapy are lacking.

PATIENTS AND METHODS

In the multicentre, randomised, biomarker discovery Microarray Analysis in breast cancer to Tailor Adjuvant Drugs Or Regimens (MATADOR) trial, patients with pT1-3, pN0-3 breast cancer were randomised (1:1) between six adjuvant cycles of doxorubicin 60 mg/m² and cyclophosphamide 600 mg/m² every 2 weeks (ddAC) and six cycles of docetaxel 75 mg/m², doxorubicin 50 mg/m² and cyclophosphamide 500 mg/m² every 3 weeks (TAC). The primary objective was to discover a predictive gene expression profile for ddAC and TAC benefit. Here we report the preplanned secondary end-point recurrence-free survival (RFS) and overall survival (OS).

RESULTS

Between 2004 and 2012, 664 patients were randomised. At 5 years, RFS was 87% (95% confidence interval [CI] 83%-91%) in the ddAC-treated patients and 88% (84-92%) in the TAC-treated subgroup (hazard ratio [HR] 0.89, 95% CI 0.62-1.28, P = 0.53). OS at 5 years was 93% (90%-96%) in the ddAC-treated and 94% (91%-97%) in the TAC-treated patients (HR 0.89, 95% CI 0.57-1.39, P = 0.61). Anaemia was more frequent in ddAC-treated patients (62/327 patients [18.9%] versus 15/319 patients [4.7%], P < 0.001) and diarrhoea (21 [6.4%] versus 53 [16.6%], P<0.001) and peripheral neuropathy (15 [4.6%] versus 46 [14.4%], P < 0.001) were observed more often in TAC-treated patients.

CONCLUSIONS

With a median follow-up of 7 years, no significant differences in RFS and OS were observed between six adjuvant cycles of ddAC and TAC in high-risk breast cancer patients.

TRIAL REGISTRATION NUMBERS

ISRCTN61893718 and BOOG 2004-04.

Abstract P1-08-09: Breast cancer-related deaths according to grade in ductal carcinoma in situ: A Dutch population-based study on patients diagnosed between 1999 and 2012

Background

The incidence of ductal carcinoma in situ (DCIS) has drastically increased over the past decades. Since DCIS is resected after diagnosis similarly to invasive breast cancer, the natural cause and behaviour of DCIS is not well known. We aimed to determine breast cancer-specific (BCSS) and overall survival (OS) according to grade in DCIS patients after surgical treatment in the Netherlands.

Patients and methods

All DCIS patients diagnosed between 1999-2012 were selected from the Netherlands Cancer Registry. Cause of death was obtained from 'Statistics Netherlands'. BCSS and OS were estimated using multivariable Cox regression in the entire cohort and stratified for grade.

Results

In total, 12,256 patients were included, of whom 1,509 (12.3%) presented with grade I, 3,675 (30.0%) with grade II, 6,064 (49.5%) with grade III and 1,008 (8.2%) with an unknown grade. During a median follow-up of 7.8 years, 1,138 (9.3%) deaths were observed, and 179 (1.5%) were breast cancer-related. Of these, 10 patients had grade I, 46 grade II, 95 grade III and 28 an unknown grade. After adjustment for confounding, grade II and III were related to worse BCSS compared to grade I with HRs of 1.92 (95% CI:0.97-3.81) and 2.14 (95% CI:1.11-4.12), respectively. No association between grade and OS was observed.

Conclusion

BCSS and OS rates in DCIS patients are excellent. Since superior rates were observed for low-grade DCIS, and earlier studies have shown that low-grade DCIS have a very low chance on recurrence or upstage to invasive cancer, it seems justified to investigate whether active surveillance may be a balanced alternative for conventional surgical treatment.

Citation Format: van Maaren MC, Lagendijk M, Tilanus-Linthorst MM, de Munck L, Pijnappel RM, Schmidt MK, Wesseling J, Koppert LB, Siesling S. Breast cancer-related deaths according to grade in ductal carcinoma in situ: A Dutch population-based study on patients diagnosed between 1999 and 2012 [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 P1-08-09.

Abstract OT2-07-07: Image-guided de-escalation of neoadjuvant chemotherapy in HER2-positive breast cancer: The TRAIN-3 study

Background

The addition of pertuzumab to trastuzumab containing chemotherapy has boosted pathologic complete response (pCR) rates after neoadjuvant chemotherapy for HER2-positive breast cancer. PCR rates over 80% have been described and achieving a pCR is associated with a favorable long-term outcome. In addition, achieving a radiologic complete response (rCR) is predictive of the pathologic response in HER2-positive tumors. Therefore it is hypothesized that image-guided evaluation based on the early occurrence of rCR can be used to tailor the number of chemotherapy cycles.

Trial design

This is a single arm, multicenter study evaluating the efficacy of image-guided de-escalation of neoadjuvant treatment with paclitaxel, Herceptin®, carboplatin, and pertuzumab (PTC-ptz). Radiologic evaluation with contrast-enhanced breast MRI and ultrasound of the axilla (in cN+ patients) is performed at baseline and after 3, 6, and 9 cycles of treatment. In case of rCR of the breast (and axilla) after 3 or 6 cycles, early surgery will be performed. If residual tumor is present after 3 and 6 cycles, patients will continue the PTC-ptz regimen to complete a total of 9 cycles. All patients will receive adjuvant Herceptin® and pertuzumab to complete 1 year of anti-HER2 blockade and endocrine treatment according to local guidelines if HR-positive. The study will be performed in the Netherlands in approximately 35 centers.

Eligibility criteria

Eligible patients have histologically proven stage II/III HER2-positive primary breast cancer with known hormone-receptor status. Patients must have a measurable breast tumor on baseline MRI and can be either node negative or node positive.

Specific aims

The aim is to evaluate the efficacy of image-guided de-escalation of neoadjuvant chemotherapy in HER2-positive breast cancer on event-free survival (EFS) at 3 years as primary endpoint. Secondary endpoints are overall survival, rCR, concordance between rCR and pCR (ypT0/is, ypN0), differences in EFS and OS following pCR between patients who received 3, 6, or 9 cycles, and toxicity.

Statistical methods

This is a single-arm, two stage study with one interim-analysis and a final analysis. Statistics will be performed for each hormone receptor subgroup separately. Stopping rules are based on 3-year EFS-rates described in literature (88% for HR-negative tumors and 90% for HR-positive tumors) and calculated using the exact conditional Poisson distribution. The study is successful with ≤34 EFS-events in the HR-negative subgroup and ≤38 events in the HR-positive subgroup after 700 patient-years of follow-up. The three-year EFS-estimate will be calculated using Kaplan-Meier statistics.

Present accrual and target accrual

Target accrual is 231 patients for the HR-negative group and 231 patients for the HR-positive group. Present accrual will follow.

Funding

Investigator initiated trial sponsored by the Dutch Breast Cancer Research Group (BOOG), funded by Roche.

Contact information for people with a specific interest in the trial

Study coordinator: A van der Voort, MD

The Netherlands Cancer Institute

1006 BE Amsterdam

E: a.vd.voort@nki.nl, P:+31 20 512 2951

Citation Format: van der Voort A, Dezentjé VO, van der Steeg WA, Winter-Warnars GA, Schipper R-J, Scholten AN, Wesseling J, van Werkhoven ED, van Duijnhoven FH, Vrancken Peeters M-JT, Sonke GS. Image-guided de-escalation of neoadjuvant chemotherapy in HER2-positive breast cancer: The TRAIN-3 study [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 OT2-07-07.

Abstract PD8-09: Approximately 40% of invasive recurrences after treatment of ductal carcinoma in situ is likely to be a second primary tumor

Background. Ductal carcinoma in situ (DCIS) is a potential precursor of invasive breast cancer, because: DCIS often accompanies invasive breast cancer; its risk factors are similar to those of invasive breast cancer; and genetic markers found in DCIS are similar to the ones found in invasive breast cancer. However, clinical behavior of DCIS is still poorly understood, as there is only limited information on its long-term natural history. Altogether, this makes it difficult to understand the relatedness of DCIS and its subsequent ipsilateral invasive breast cancer (iIBC). Here, we set-up a comparison between primary DCIS and matched subsequent iIBC, by making use of pathological and molecular data.

Patients and methods. For this study, we used a unique series of 155 DCIS cases which developed a subsequent iIBC during a median follow up period of 12.6 years. We assessed histological characteristics, tumor location, estrogen and progesterone receptor status, p16 expression, and HER2 and p53 overexpression. RNA sequencing and copy number sequencing was done on 78 DCIS lesions and 78 matched invasive breast cancer relapses. We determined if the iIBC lesion and DCIS lesion were related, with respect to tumor location, immunohistochemical (IHC) markers, and genomic features.

Results. Based on tumor location and histological grade, &gt;95% of the subsequent invasive breast cancers reflected outgrowth of residual disease. HER2 was the only IHC marker that showed a significant difference in expression between DCIS and matched iIBC: 40% of the HER2 positive DCIS was followed by a HER2 negative invasive recurrence. In addition, RNAseq data was used to classify DCIS and IBC lesions into PAM50 subtypes. 77% of the DCIS IBC pair belonged to the same subtype. The DCIS lesions showed copy number aberrations on typical breast cancer-associated loci. However, when we compared the DCIS with its matched iIBC, we saw in 41% of the cases very distinct copy number profiles, indicating either outgrow of a different tumor subclone or a second primary.

Conclusion. This is the first time that a sound comparison could be made between primary DCIS and its subsequent invasive breast cancer with such a large patient group, integrating pathological and molecular data. Our results strongly suggest that many subsequent iIBCs after treatment of pure DCIS could be considered as second primary breast cancer lesions. To provide definite proof for this, in depth DNA sequencing and heterogeneity studies will be presented at SABCS 2018.

Citation Format: Visser LL, Hoogstraat M, Elshof LE, van de Vijver K, Groen EJ, Almekinders MM, Bierman C, Nieboer F, de Maaker M, Kristel P, Mulder L, Schaapveld M, Schmidt MK, Lips E, Wesseling J. Approximately 40% of invasive recurrences after treatment of ductal carcinoma in situ is likely to be a second primary tumor [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 PD8-09.

Abstract P2-07-04: Prognostic value of residual cancer burden (RCB), neo-bioscore and neoadjuvant response index (NRI) to evaluate response to neoadjuvant trastuzumab-based therapy in HER2-positive breast cancer (BC)

Intro Pathological complete response (pCR) to neoadjuvant systemic therapy is associated with favorable long-term outcome. As pCR is not an optimal surrogate marker for outcome, other tools were developed to predict long-term outcome more accurately, including the RCB4, NRI3, and Neo-Bioscore5. We evaluated the prognostic value of these tools in a cohort of patients with HER2+ BC with the aim of selecting a group of patients with residual disease but a similar long-term outcome as patients achieving pCR.

Methods We included all patients with stage II-III HER2+ BC who were treated with trastuzumab-based neoadjuvant therapy and surgery in the Netherlands Cancer Institute between November 2004 and December 2016. Patients were identified from the institutes' tumor registry and data was collected from the patients' records. To assess RCB scores surgical specimens (breast and axilla tissue) of patients without pCR were retrospectively reviewed. NRI and Neo-Bioscore were calculated based on original pathology reports.

Primary endpoint was recurrence-free interval (RFI), defined as time since diagnosis of BC till locoregional or distant recurrence or death from BC, whatever came first. Cox proportional models were used with transformations of RCB, NRI, and Neo-Bioscore. In addition, we evaluated at which cut-off point the NRI could select patients with a similar good prognosis as patients who achieved a pCR, defined by the same lower bound of the 95%CI of the 5-year RFI estimate for the pCR-group.

Results 283 women were included, 149 (53%) with HER2+/ER+ BC. 28% received dual HER2-blockade. Median follow-up was 66 months (range 11-148). 157 patients (55%) achieved a pCR in breast and axilla; predicted 5-year RFI for this group was 91% (95%CI 86-96), HR no-pCR vs pCR 2.19, 95%CI 1.07-4.47. Table 1 shows the predicted 5-year RFI and HR for RCB classes. The HR of an RFI event increases gradually for lower NRI values compared to NRI of 1 and gets more steep near NRI values of 0. Patients with a NRI of ≥0.80-0.99 have a 5-year RFI estimate of 90% (95%CI 86-96), HR 1.1 (95%CI 0.6-1.9) compared to patients with NRI of 1 (which is pCR). Table 2 shows the predicted 5-year RFI and HR for the Neo-Bioscore.

Table 1RCB classes, estimated 5-year RFI and HRRCBn% 5-year RFI95% CIHR95% CI016392.688.397.111113990.385.295.61.330.672.6526278.469.488.53.181.427.1131135.316.476.113.605.3034.81

Table 2Neo-Bioscore classes, predicted 5-year RFI and HRNeo-Bioscoren% 5-year RFI95% CIHR95% CI01998.795.510011115392.486.099.36.100.9240.5229384.977.493.012.670.76210.4037289.983.896.58.200.62108.2041974.962.989.222.331.76283.445329.410.384.095.206.271446.64610.601.00406.2619.558442.21

Conclusions We show that in a HER2+ BC cohort the RCB and NRI are able to identify a subgroup of patients with limited residual disease after neoadjuvant therapy with similar good prognosis as patients with pCR and therefore may not benefit from additional adjuvant therapy.

References

1 Cortazar Lancet 2014

2 FDA Regist 2014

3 Rodenhuis Ann Oncol 2010

4 Symmans JCO 2007

5 Jeruss JCO 2008

6 Mittendorf JAMA Oncol 2016

Citation Format: Steenbruggen TG, van Seijen M, Janssen LM, van Ramshorst MS, van Werkhoven E, Lips EH, Vrancken-Peeters M-JT, Horlings HM, Wesseling J, Sonke GS. Prognostic value of residual cancer burden (RCB), neo-bioscore and neoadjuvant response index (NRI) to evaluate response to neoadjuvant trastuzumab-based therapy in HER2-positive breast cancer (BC) [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 P2-07-04.

Abstract OT3-07-01: Update of the randomized, non-inferiority LORD trial testing safety of active surveillance for women with screen-detected low risk ductal carcinoma in situ (EORTC-1401-BCG/BOOG 2014-04, DCIS)

The introduction of population-based breast cancer screening and implementation of digital mammography have led to an increased incidence of ductal carcinoma in situ (DCIS) without a decrease in the incidence of advanced breast cancer. This suggests DCIS overdiagnosis exists.

We hypothesize that asymptomatic, low-grade DCIS can safely be managed by active surveillance. If progression to invasive breast cancer would still occur, this will be low-grade and hormone receptor positive with excellent survival rates. Also, breast-conserving treatment will still be an option, if no prior radiotherapy has been applied. Management by active surveillance also may save many low-grade DCIS patients intensive treatment.

Therefore, we will compare active surveillance with conventional treatment, being either mastectomy, wide local excision (WLE) only, or WLE plus radiotherapy, possibly followed by hormonal therapy for primary low-grade DCIS. For this, we conduct a phase III, open-label, non-inferiority, multi-center, randomized clinical trial sponsored by the European Organization for Research and Treatment of Cancer (EORTC-1401-BCG). The Dutch Centers are coordinated by the Dutch Breast Cancer Research Group (BOOG) (BOOG 2014-04). This trial is developed and implemented in close collaboration with patient advocates.

Randomization will be in a 1:1 ratio among one of the following arms: (1) active surveillance or (2) standard treatment per local policy. In total, 1,240 women (≥ 45 years) will be included without prior breast cancer, but with asymptomatic, pure, low-grade DCIS, based on a minimum of tissue harvested by biopsy from calcifications detected by population-based or opportunistic screening. Assuming 25% of randomized women qualified to enroll in the study will drop out or will be excluded from per protocol evaluation, at least 1,240 women need to be randomized to obtain the 930 patients required for the evaluation of the primary endpoint. The same follow-up scheme will be applied in both study arms, i.e. annual mammography for a period of 10 years. The primary end-point is ipsilateral invasive breast tumor-free rate at 10 years. Secondary end-points are among others: overall survival, breast cancer-specific survival, mastectomy rate, patient reported outcomes and cost-effectiveness. Accrual has started in the Netherlands in February 2017 and will start internationally in over 30 centers shortly.

Acknowledgements: This trial is funded by Pink Ribbon Netherlands, the Dutch Cancer Society and Dutch Cancer Society/Alpe d'HuZes, and Cancer Research UK.

Citation Format: Wesseling J, Elshof LE, Tryfonidis K, Poncet C, Aalders K, van Leeuwen-Stok E, Skinner V, Loo C, Winter-Warnars G, Bleiker E, Retèl V, Pijnappel R, Bijker N, Rutgers E, van Duijnhoven F. Update of the randomized, non-inferiority LORD trial testing safety of active surveillance for women with screen-detected low risk ductal carcinoma in situ (EORTC-1401-BCG/BOOG 2014-04, DCIS) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT3-07-01.

Abstract P2-03-10: Risk factors for upgrading and upstaging of pre-operative biopsies in ductal carcinoma in situ

Background: Ductal carcinoma in situ (DCIS), accounts for one fifth of all screen-detected neoplastic breast lesions. Contemporary research in DCIS focuses on separating lesions that need active treatment from those that can be safely left under surveillance. This, in turn, relies on accurate determination of invasive status and DCIS grade at time of initial biopsy. Most previous studies have examined factors associated with upstaging the diagnosis from DCIS to invasive breast cancer (IBC) following surgery, and few have evaluated factors associated with upgrading the diagnosis to a higher grade of DCIS. This is because upgrading has not traditionally influenced clinical management in the way that upstaging has done. However, recent interest in non-operative treatment for low-risk DCIS has meant that accurate determination of grade at time of initial biopsy has become more important. We aimed to compare risk factors for upgrading and upstaging of biopsies in DCIS.

Method: We undertook a cohort study of all women diagnosed with DCIS at a large specialist cancer centre between 2000–2014. Information from the clinical records was abstracted, including the pre-operative mammography (MMG) and pathology information from the initial biopsy. We also abstracted pathology information regarding the excised specimen in order to identify women whose diagnosis was subsequently upgraded or upstaged. We looked for factors that were predictive for upgrading or upstaging.

Result: A total of 641 women were diagnosed with DCIS at initial biopsy. Of these, 72 (11%) were upgraded: 26 (4%) from grade 1 to grade 2, 2 (0.3%) from grade 1 to grade 3 and 44 (7%) from grade 2 to grade 3. A further 115 (18%) were upstaged to IBC: 20 of these (3%) had grade 1 DCIS on initial biopsy, 47 (7%) had grade 2, 43 (7%) grade 3, and for 5 (1%) biopsy grade was not available. Necrosis on biopsy increased the risk of upgrading (with necrosis: 14% upgraded, without: 10% upgraded, p for difference 0.02) and also of upstaging (with necrosis: 23% upstaged, without: 15% upstaged, p for difference &lt;0.01). Lesions measuring ≥50 mm on MMG were more likely to be upgraded than smaller lesions (0-19 mm: 9% upgraded, 20-50 mm: 9% upgraded, ≥50 mm: 19% upgraded, p for heterogeneity &lt;0.01), while lesions measuring 20-50 mm and ≥50 mm were both more likely to be upstaged than lesions measuring 0-19 mm (0-19 mm: 9% upstaged, 20-50 mm: 23% upstaged and ≥50 mm: 21% upstaged, p for heterogeneity &lt;0.01). Fewer 9G vacuum-assisted biopsies than 14G core biopsies were upgraded (9G vacuum-assisted: 7% upgraded, 14G core: 15% upgraded, p for difference 0.01), while the effect of biopsy method on upstaging was not significant (9G vacuum-assisted: 12% upstaged, 14G core: 16% upstaged, p for difference 0.15). Presence of a palpable lump was not significantly associated with upgrading (palpable lump: 13% upgraded, no palpable lump: 10% upgraded, p for difference 0.19) but increased the risk of upstaging (palpable lump: 23% upstaged, no palpable lump: 16% upstaged, p for difference 0.02).

Conclusion: Our findings suggest that consideration of MMG lesion size and necrosis on biopsy may be helpful in selecting low-risk women for non-operative management of DCIS, as may use of the 9G vacuum-assisted method of biopsy.

Citation Format: Mannu GS, Groen E, Wang Z, Schaapveld M, Lips E, Chung M, Joore I, Leeuwen Fv, Teerstra J, Winter-Warnars GAO, Darby SC, Wesseling J. Risk factors for upgrading and upstaging of pre-operative biopsies in ductal carcinoma in situ [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-03-10.

Abstract P4-15-13: When is cancer not really cancer? The PREvent ductal carcinoma in situ invasive overtreatment now (PRECISION)* initiative

Background

Ductal carcinoma in situ (DCIS) now represents 20-25% of all breast neoplasia due to large-scale detection by widely adopted population-based breast cancer screening programs. As a result, thousands of women are confronted with DCIS each year: more than 8,000 in the UK, 2,500 in the Netherlands, and some 50,000 in the US. Conventional management includes surgery, supplemented by radiotherapy and/or endocrine therapy, but overtreats the majority of DCIS as ˜1% recur annually and breast cancer mortality is ˜3% at 20 years. Uncertainty as to which DCIS lesions will progress to invasive cancer or, after excision, which will return with recurrent DCIS or invasive breast cancer drives this overtreatment. This urges us to learn how to distinguish DCIS that may progress to invasive breast cancer from the majority of indolent DCIS. Such distinction may be best achieved by synergistic international collaboration between leading global experts from various disciplines, driven by the essential input from patient voices as full members of the research team.

Aim

PRECISION (PREvent ductal Carcinoma In Situ Invasive Overtreatment Now) aims to save thousands of women with low risk DCIS the burden of intensive inappropriate treatment of DCIS (surgery, radiation therapy, hormonal therapies) through the discovery of new data and development of novel tests that promote informed and shared decision-making between patients and clinicians, without compromising the excellent outcomes for DCIS management presently achieved.

Methods

First, three large DCIS cohorts and supplementary resources will be collected enabling in depth molecular studies. Second, extensive genomic characterization, immune profiling and imaging analysis will be performed. In vivo and in vitro modeling will be performed to study the biology of DCIS in detail. Finally, all clinical, immune, and molecular data will be incorporated into a clinical risk prediction model. This risk prediction model will be validated in three prospective randomized DCIS trials in the US (COMET trial), UK (LORIS trial), and mainland Europe (LORD trial).

How the results of this research will be used

The discoveries from our laboratory studies, including a risk stratification model, will be cross-validated in three prospective trials of DCIS active surveillance versus conventional treatment (the COMET, LORIS and LORD trials). As such, the main result of this study will be that we can identify a group of women for which active surveillance for DCIS could be a safer alternative to intensive treatment. Ultimately, this may also contribute to a more reassuring perception of risk regarding non-life threatening precancerous lesions in general, reducing anxiety and preserving quality of life.

* The PRECISION Team is a Cancer Research UK Grand Challenge Award 2017 winning team and will be jointly funded by Cancer Research UK and the Dutch Cancer Society.

Citation Format: Wesseling J, Thompson A, Nik-Zainal S, Futreal A, Hwang S, Jonkers J, Lips E, Rea D, On Behalf of the PRECISION Team. When is cancer not really cancer? The PREvent ductal carcinoma in situ invasive overtreatment now (PRECISION)* initiative [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-15-13.

Abstract P5-14-03: Adjuvant dose dense doxorubicin-cyclophosphamide (ddAC) or docetaxel-AC (TAC) for high-risk breast cancer: First results of the randomized MATADOR trial (BOOG-2004-04)

Background: Anthracycline-based adjuvant chemotherapy has substantially improved breast cancer survival. Both the addition of taxanes as well as using a dose dense treatment schedule can further ameliorate outcome, but inter-individual differences exist. Here we present the efficacy and toxicity of dose dense scheduled doxorubicin/cyclophosphamide (ddAC) versus docetaxel/doxorubicin/cyclophosphamide (TAC), which is, to our knowledge, the first direct comparison of these treatment regimens.

Methods: In this Dutch, multicenter phase III trial (ISRCTN61893718), patients with pT1-3, pN0-3, M0 breast cancer were randomized between six cycles of either A60C600 every 2 weeks or T75A50C500 every 3 weeks. All patients received pegfilgrastim. Patients were evaluated for recurrence-free survival (RFS) and overall survival (OS). Survival was compared in a Cox regression analysis and adjusted for known prognostic factors. These factors include age, type of surgery, tumor size, histological grade, ER/PR status, HER2 status, and lymph node status. Adverse events were reported according to the common toxicity criteria (CTCAE version 3.0).

Results: Between 2004 and 2012, 664 patients were enrolled of whom 531 (80%) had node positive disease. At a median follow up of 5 years, OS was 92% in the ddAC treated subgroup and 93% in the TAC treated subgroup (adjusted hazard ratio [HR] 0.75, 95% confidence interval [CI] 0.42-1.34, intention to treat population). Forty-two breast-cancer specific deaths were equally divided over both treatment arms. Similarly, no significant difference in RFS was observed between both treatment groups (adjusted HR 0.85, 95% CI 0.55-1.32). Molecular subtypes were defined by St. Gallen criteria: 548 patients (83%) had estrogen receptor positive disease and 102 patients (15%) triple negative disease. No heterogeneity regarding treatment efficacy was observed in these subtypes. In particular, there was no survival benefit for ddAC or TAC in the triple negative subtype. Both treatment regimens were well tolerated. Whereas anemia was more frequent in ddAC treated patients (19% vs 4.7%; p&lt;0.001), peripheral neuropathy occurred more frequently in TAC treated patients (4.6% vs 14.4%; p&lt;0.001). The frequency of febrile neutropenia was not significantly different between the treatment arms (11% vs 12.5%; n.s.). Six patients developed congestive heart failure: 2 ddAC treated patients, 4 TAC treated patients. One ddAC treated patient and one TAC treated patient were diagnosed with acute myeloid leukemia after study treatment; another patient in the ddAC treatment group developed myelodysplastic syndrome.

Conclusions: At a median follow up of 5 years no significant survival differences were observed between adjuvant ddAC and TAC, in all patients and in molecular subgroups, including triple negative. Our findings are in line with the Oxford overview, which reported no significant differences between taxane-based chemotherapy and more, non-taxane based chemotherapy given in a dose dense schedule. ddAC could be a reasonable alternative for patients with a contra-indication for TAC.

Citation Format: van Rossum AGH, Oosterkamp HM, van Werkhoven E, Opdam M, Mandjes IAM, van Leeuwen-Stok E, van Tinteren H, Kok M, Imholz ALT, Portielje JEA, Bos MMEM, van Bochove A, Wesseling J, Rutgers EJ, Rodenhuis S, Linn SC. Adjuvant dose dense doxorubicin-cyclophosphamide (ddAC) or docetaxel-AC (TAC) for high-risk breast cancer: First results of the randomized MATADOR trial (BOOG-2004-04) [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 P5-14-03.

Abstract PD1-07: Comprehensive characterization of matched pre-treatment biopsies and residual disease of doxorubicin treated breast cancer

Background

Neoadjuvant chemotherapy is standard of care for locally advanced breast cancer. Unfortunately not all patients benefit from this treatment. Even after decades of research, we still cannot predict which tumor will or will not respond. This may in part be due to tumor heterogeneity, as the sample taken before treatment not necessarily represents the tumor cell population that causes therapy resistance.

Methods

To test this hypothesis, we collected pre-treatment biopsies, resection specimens, and matched blood from 21 breast cancer patients treated with doxorubicin and cyclophosphamide in a neoadjuvant setting. Specifically, tumors were selected with a tumor percentage &gt;50% after chemotherapy to enrich for resistant samples and ensure high quality data. RNA and whole exome sequencing were performed to characterize somatic mutations, copy number alterations and gene expression profiles. Histopathological characteristics were determined to obtain a comprehensive profile of all tumor samples.

Results

The comparisons of somatic variants and copy number alterations revealed a very diverse image: in several cases, high-level amplifications, large genomic gains or losses, and mutations in known oncogenes or tumor suppressors such as MAP3K1 and RUNX1 were either lost or gained during treatment, while in other cases no such changes were detected. We observed a remarkable number of genetic alterations involved in cell cycle progression and DNA damage checkpoints, including amplification of MDM2, CCND1 and CDK4, and copy number loss or mutations in CDKN1B and ATM. Strikingly, both cases of CDKN1B loss were identified in pre-treatment biopsies and no longer detectable in the surgery specimen. In contrast, CCND1, CDK4 and MDM2 amplifications were retained, although CCND1 expression decreased significantly in CCND1 amplified tumors.

In addition, eighty percent of tumors showed a decreased cell proliferation after chemotherapy, where the high-proliferative ER+ (Luminal B) tumors were most strongly affected. This trend was also visible in a validation cohort of 94 ER+ samples, but the prognosis of Luminal B tumors that showed a decrease in proliferation was still significantly worse than that of Luminal A tumors that did not show an altered proliferation rate.

Conclusion

Our results confirm that biologically relevant genomic alterations can differ between pre- and post-treatment samples, which greatly impacts biomarker discovery. In addition, our findings emphasize the chemotherapy insensitivity of CCND1 amplified ER+ breast cancers, and stress the need for better treatment regimens for these patients. In contrast, genomic loss of CDKN1B may be a marker for sensitivity to doxorubicin.

Citation Format: Lips EH, Hoogstraat M, Mulder L, Nederlof PM, Sonke GS, Rodenhuis S, Wesseling J, Wessels LFA. Comprehensive characterization of matched pre-treatment biopsies and residual disease of doxorubicin treated breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD1-07.

Abstract OT1-01-08: Intensified alkylating chemotherapy in patients with oligo-metastatic breast cancer harboring homologous recombination deficiency: The OLIGO study

Background Approximately 5% of patients with metastatic breast cancer survive more than 10 years. Long-term survival is mostly seen in patients with limited metastatic disease, often referred to as 'oligo'-metastatic disease. Oligo-metastatic breast cancer is variably defined as a maximum of 3-5 metastases beyond the regional lymph nodes. Some believe that oligo-metastatic cancer can be treated with curative intent using a multidisciplinary approach that targets the detected metastases, circulating micro-metastases, and any locoregional disease if present. Optimal patient selection is of vital importance.

Intensified alkylating chemotherapy in the treatment of breast cancer patients is controversial, as older studies have not shown a survival benefit in unselected groups of patients. More recent retrospective analyses, however, have suggested that patients with homologous recombination deficiency (HRD) derive significant benefit from intensified chemotherapy in comparison to conventional chemotherapy.

Trial design In this phase 3 trial patients with oligo-metastatic breast cancer and HRD start with 3 cycles of induction chemotherapy. Chemotherapy schedule includes anthracyclines and taxanes in treatment naïve patients and is personalized according to previously received (neo-)adjuvant chemotherapy in others. Patients with at least stable disease after 3 cycles are 1:1 randomized to receive another 3 cycles of conventional chemotherapy or progenitor cell mobilization with cyclophosphamide followed by 2 cycles of intensified chemotherapy (carboplatin 400 mg/m2 (day 1&2), thiotepa 250 mg/m2 (day 2), and cyclophosphamide 3000 mg/m2 (day 1)) and peripheral blood progenitor cell reinfusion. Following systemic treatment, all patients receive maximal local therapy of locoregional and distant disease with surgery and/or radiotherapy.

Eligibility criteria Eligible patients have histologically proven, HER2 negative, oligo-metastatic breast cancer (1-3 distant metastatic lesions), with or without locoregional disease, either as de novo disease or recurrence. All lesions must be amenable to surgery or radiotherapy with curative intent. The tumor has to be deficient in homologous recombination by array comparative genomic hybridization and no prior chemotherapy for metastatic disease is allowed.

Specific aim To study the difference in event-free survival (EFS) between intensified alkylating chemotherapy compared to standard chemotherapy as part of a multimodality treatment approach in patients with oligo-metastatic breast cancer harboring HRD.

Statistical methods and patient accrual Primary endpoint of the study is EFS at 3 years. Toxicity, time to recurrence, and overall survival will be evaluated as secondary endpoints. A total of 65 EFS events will provide 80% power to detect a hazard ratio of 2.0 between treatment arms at the 0.05 two-sided significance level. Assuming an accrual period of 48 months and a maximum follow-up time of 60 months, 86 patients are required. At the time of abstract submission, 33 patients were randomized.

Contact information Principal investigator: Dr. GS Sonke, g.sonke@nki.nl. Study coordinator: TG Steenbruggen, t.steenbruggen@nki.nl. Clinicaltrials.gov: NCT01646034.

Citation Format: Steenbruggen TG, Vrancken Peeters M-JTFD, Scholten AN, Schot M, Wesseling J, Linn SC, Sonke GS. Intensified alkylating chemotherapy in patients with oligo-metastatic breast cancer harboring homologous recombination deficiency: The OLIGO study [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 OT1-01-08.

Abstract P5-08-07: The long-term prognosis of breast cancers patients diagnosed ≤40 years in the absence of adjuvant systemic therapy

This abstract was withdrawn by the authors.

Abstract P1-03-04: Concordance of local immunohistochemistry with TargetPrint microarray based assessment of ER, PR and Her2 and BluePrint molecular subtyping in the Symphony Triple A study

PURPOSE: A decade ago intrinsic biological breast cancer subtypes have been identified which have proven to be of clinical importance in terms of outcome and response to systemic treatment. The aim of the current study is to assess concordance between breast cancer subtypes determined by local immunohistochemistry (IHC) assessment of estrogen receptor (ER), progesterone receptor (PR) and Her2-receptor status and microarray based molecular subtyping in a subset of ER+ early stage breast cancer patients.

PATIENTS AND METHODS: In this prospective observational multicenter study information on local pathology assessment and BluePrint/TargetPrint results were obtained in ER+ Dutch early stage breast cancer patients in whom a 70-gene profile (MammaPrint) was used as they were enrolled in clinical trial based on the existence of controversy regarding the additional value of adjuvant CT. Local IHC assessment of ER, PR and Her2 status were compared with microarray based assessment (TargetPrint/BluePrint) of these characteristics. Reclassification of ER and PR overexpression was assessed by a McNemars test and by Spearman correlation. Furthermore, concordance between the clinical subtypes based on local pathology (Luminal-type: ER+/PR+/Her2-; Her2-type: Her2+ disease) and molecular subtyping was assessed.

RESULTS: Between January 2013 And December 2015 660 patients, treated in 31 hospitals, were enrolled. In 564 (85%) BluePrint and/or TargetPrint was performed in addition to the 70-GS. The majority of patients had ER+/Her2- disease and TargetPrint reclassified 1% (n = 7) of patients as ER-negative (r = 0,250, p &lt;0,001). TargetPrint reclassified 7% (n = 40) and 2% (n = 11) of patients for PR and Her2 status respectively (table 1, r = 0,580, p &lt;0,001 for PR

Table 1. Concordance between immunohistochemistry and TargetPrint. TargetPrint result (ER, PR and Her2 resp.)  ImmunohistochemistryPositiveNegativeOverall discordance (%)p-value*Estrogenreceptor status    Positive557 (99%)6 (1%)  Negativen.a.n.a.1%n.a.Progesterone receptor status    Positive474 (96%)18 (4%)  Negative22 (31%)49 (69%)7%0,636Her2 receptor status    Positive3 (30%)7 (70%)  Negative4 (3%)546 (97%)2%0,549Equivocal0 (0%)3 (1%)  * P-value represents results of the McNemar test.). Based on IHC 545 (98%) patients were regarded as luminal-type and the remaining 2% as Her2-type. BluePrint reclassified 2% of the clinical luminal-type patients: 4 (1%) patients were reclassified as basal-type and 3 (0%) patients as Her2-type. Of the clinical Her2-type patients 80% (n=8) was reclassified by BluePrint as molecular luminal-type.

Table 2. Concordance between clinical subtyping and molecular subtyping according to BluePrint.  BluePrint resultClinical SubtypeNo. ptsLuminalBasalHer2Luminal545539 (99%)4 (1%)3 (0%)Her2108 (80%)02 (20%)Note. Overall discordance 3%.

Conclusion: In the current study we observe a high concordance between microarray-based assessment of ER, PR and Her2 and local pathology in Dutch ER+ early stage breast cancer patients. In the small subset of ER+ patients who are considered candidates for 70 GS use and who have HER2+ tumors by IHC molecular typing of HER2 status is of additional value.

Citation Format: Kuijer A, Straver M, Elias S, Smorenburg C, Wesseling J, Linn S, Rutgers E, Siesling S, van Dalen T. Concordance of local immunohistochemistry with TargetPrint microarray based assessment of ER, PR and Her2 and BluePrint molecular subtyping in the Symphony Triple A study [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 P1-03-04.

Defining hip pain trajectories in early symptomatic hip osteoarthritis--5 year results from a nationwide prospective cohort study (CHECK)

OBJECTIVE

To define distinct hip pain trajectories in individuals with early symptomatic hip osteoarthritis (OA) and to determine risk factors for these pain trajectories.

METHOD

Data were obtained from the nationwide prospective Cohort Hip and Cohort Knee (CHECK) study. Participants with hip pain or stiffness and a completed 5-year follow-up were included. Baseline demographic, anamnestic, physical examination characteristics were assessed. Outcome was annually assessed by the Numeric Rating Scale (NRS) for pain. Pain trajectories were retrieved by latent class growth analysis (LCGA). Multinomial logistic regression was used to calculate risk ratios.

RESULTS

545 participants were included. Four distinct pain trajectories were uncovered by LCGA. We found significant differences in baseline characteristics, including body mass index (BMI); symptom severity; pain coping strategies and in criteria for clinical hip OA (American College of Rheumatology (ACR)). Lower education, higher activity limitation scores, frequent use of pain transformation as coping strategy and painful internal hip rotation were more often associated with trajectories characterized by more severe pain. No association was found for baseline radiographic features.

CONCLUSION

We defined four distinct pain trajectories over 5 years follow-up in individuals with early symptomatic hip OA, suggesting there are differences in symptomatic progression of hip OA. Baseline radiographic severity was not associated with the pain trajectories. Future research should be aimed at measuring symptomatic progression of hip OA with even more frequent symptom assessment.

Sentinel lymph node biopsy can be omitted in DCIS patients treated with breast conserving therapy

Breast cancer guidelines advise sentinel lymph node biopsy (SLNB) in patients with ductal carcinoma in situ (DCIS) on core biopsy at high risk of invasive cancer or in case of mastectomy. This study investigates the incidence of SLNB and SLN metastases and the relevance of indications in guidelines and literature to perform SLNB in order to validate whether SLNB is justified in patients with DCIS on core biopsy in current era. Clinically node negative patients diagnosed from 2004 to 2013 with only DCIS on core needle biopsy were selected from a national database. Incidence of SLN biopsy and metastases was calculated. With Fisher exact tests correlation between SLNB indications and actual presence of SLN metastases was studied. Further, underestimation rate for invasive cancer and correlation with SLN metastases was analysed. 910 patients were included. SLNB was performed in 471 patients (51.8 %): 94.5 % had pN0, 3.0 % pN1mi and 2.5 % pN1. Patients undergoing mastectomy had 7 % SLN metastases versus 3.5 % for breast conserving surgery (BCS) (p = 0.107). The only factors correlating to SLN metastases were smaller core needle size (p = 0.01) and invasive cancer (p < 0.001). Invasive cancer was detected in 16.7 % by histopathology with 15.6 % SLN metastases versus only 2 % in pure DCIS. SLNB showed metastases in 5.5 % of patients; 3.5 % in case of BCS (any histopathology) and 2 % when pure DCIS was found at definitive histopathology (BCS and mastectomy). Consequently, SLNB should no longer be performed in patients diagnosed with DCIS on core biopsy undergoing BCS. If definitive histopathology shows invasive cancer, SLNB can still be considered after initial surgery.

Abstract P5-17-09: Biomarkers to distinguish hazardous from harmless ductal carcinoma in situ (DCIS) of the breast

Background. The incidence of DCIS has increased since the introduction of population-based screening. This has not resulted in a decrease in invasive breast cancer incidence, implying overdiagnosis exists. All women with DCIS are still intensively treated, by surgery, radiotherapy, and/or hormonal treatment, although only a minority will develop a subsequent invasive breast cancer. As we cannot discriminate such hazardous from harmless DCIS lesions, accurate prognostic biomarkers are urgently needed. In the current study we aim to identify molecular markers for DCIS aggressiveness, using a large population-based cohort.

Patients and methods. We used a population-based, nation-wide cohort consisting of 10,090 women treated for primary DCIS between 1989 and 2004 with a median follow-up time of 10.7 years. Within this cohort, a case-control study was set up to analyse which markers are associated with progression to invasive breast cancer. Formalin-fixed paraffin embedded (FFPE) tissue blocks were retrieved from 1580 DCIS patients who were treated by breast conserving surgery without radiotherapy (316 DCIS patients with a subsequent ipsilateral invasive breast cancer (iiBC): i.e. the "cases"; and 1264 DCIS patients without subsequent invasive breast cancer: i.e. the "controls"). A first study using this population-based cohort will involve immunohistochemistry (IHC) on 200 "cases" and 500 "controls" for an 8-marker IHC panel (ER, PR, HER2, Ki67, p16, p53, COX-2, and Annexin A1). Molecular subtypes of the DCIS and invasive breast cancer lesions will be determined and intra-individual heterogeneity will be assessed. IHC marker expression will be both compared between "cases" and " controls" as well as between DCIS lesions and its subsequent invasive breast cancer. In a second study, DNA and RNA will be isolated from these specimens, using laser microdissection, and extensive molecular profiling will be performed.

Results. We have collected FFPE tissue blocks of 287 "cases" and 1149 "controls" (86% of requested material) from 56 participating hospitals. At present, the specimens of 223 "cases" (matched DCIS and iiBC specimen) and 103 "controls" have been centrally revised for extensive morphological characteristics. Only a small part (14%) of the specimens had to be excluded from the study population. IHC staining of the tissue specimens, using the 8-marker IHC panel is ongoing.

Conclusion. Within a nation-wide cohort of 10,090 patients diagnosed with primary DCIS, we were able to collect tissue material of a representative case-control series of 200 "cases" with subsequent invasive breast cancer and 500 invasive breast cancer-free "controls". This is the first time such a large unique, unbiased DCIS series, with long-term follow-up is analysed integrating clinical, histological, and immunohistochemical data. The results will be presented at SABCS 2015.

Citation Format: Visser L, Elshof L, Groen E, van de Vijver K, Lips E, de Maaker M, Nieboer F, Schaapveld M, Rutgers E, Wesseling J. Biomarkers to distinguish hazardous from harmless ductal carcinoma in situ (DCIS) of the breast. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-17-09.

Abstract P6-08-06: Neoadjuvant tamoxifen therapy synchronizes ERα binding and gene expression profiles

Background: The majority of breast cancer patients are diagnosed with ERα-positive breast cancer. Most ERα-positive patients are treated with adjuvant endocrine therapy — typically tamoxifen or aromatase inhibitors — to block cellular proliferation. Although these treatments are considered successful, resistance is common. Notably, cross-resistance between the two types of therapies is not always observed suggesting molecular heterogeneity and underlining the need for development of personalized treatments. The Anastrozole, Fulvestrant or Tamoxifen Exposure — Response in molecular profile study (AFTER study, NCT00738777) aims to investigate prospectively whether short-term treatment can induce molecular changes indicative of pre-operative therapy response. Study Design: ERα-positive breast cancer patients are included in this open-label multicenter study. Post-menopausal patients are randomized between tamoxifen, anastrozole and fulvestrant and pre-menopausal and male patients receive tamoxifen. Treatment occurs during the pre-operative window between diagnosis and surgery (4±2 weeks). Clinical characteristics collected are ERα/PR and HER2 status as well as lymph-node status. The primary endpoint is the decrease in tumor cell proliferation, as assessed by Ki67 gene expression and published cell proliferation gene expression signatures. All data are collected from both pre- and post-treatment samples. Additionally, we will compare the changes induced by treatment in gene expression, ERα/DNA binding interactions, DNA copy number, endoxifen and estradiol levels. Results: Among 67 patients currently enrolled, we examined the data from the subset of 28 tamoxifen treated patients. ERα and PR levels did not differ significantly between pre- and post-treatment. All tumors were HER2-negative. Proliferation examined by Ki67 (IHC and gene expression, MKI67) was significantly lower in post-treatment samples (P &lt; 0.01). A significant association was identified with the change in gene expression proliferation signature score and change in MKI67 (rho = 0.7, P &lt; 0.001). We identified two samples, which changed from MammaPrint (MP) low-risk to high-risk among 17 pairs with data. One sample's score was on the cutoff for high-risk definition. Interestingly, the second sample also had an increase in Ki67 gene expression and proliferation gene signature score in the post-treatment sample. Overall, ERα/DNA binding interaction regions overlapped significantly more among post-treatment samples as compared to pre-treatment samples (P &lt;0.001). There were 3 samples that increased in MKI67 gene expression after drug exposure. Among these, only the MP low- to high-risk sample had an increase in proliferation gene signature and decrease in ERα/DNA binding interactions. Conclusions: Pre-treatment samples were more variable for both proliferation gene expression signatures and ERα/DNA binding interactions indicating the underlying molecular heterogeneity of the group prior to therapy. This inter-tumor heterogeneity appears to have been lowered by exposure to tamoxifen. Interestingly, not all samples were uniform in their response to tamoxifen exposure as measured by Ki67 and MP scores suggesting samples taken after treatment exposure may be useful for predictive biomarker discovery.

Citation Format: Linn SC, Severson TM, Nevedomskaya E, Peeters J, van Rossum A, Kuilman T, Krijgsman O, Goossens I, Glas A, Koornstra R, Peeper D, Wesseling J, Simon I, Wessels L, Zwart W. Neoadjuvant tamoxifen therapy synchronizes ERα binding and gene expression profiles. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-08-06.

Abstract P5-17-06: Prognostic value of method of detection in primary pure DCIS

Background

Population-based mammographic screening programs have led to a substantial increase in incidence of ductal carcinoma in situ (DCIS). We assessed whether the method of detection provides prognostic information among women with DCIS detected through the Dutch screening program (screen-detected DCIS) and those with DCIS not detected within the national screening program (non-screen-detected DCIS). This could have impact on the treatment strategy of screen-detected DCIS as compared to symptomatic DCIS.

Methods

We studied a population-based retrospective cohort comprising 7,106 women aged 49-76 years with primary pure DCIS, who were treated by mastectomy or breast conserving surgery with or without radiotherapy between 1989 and 2004 in the Netherlands. Risk of subsequent ipsilateral and contralateral invasive breast cancer and overall survival among women with screen-detected (n=4,905) and non-screen-detected (n=2,201) DCIS were compared using Cox regression, adjusting for treatment (time-dependent), age (time-scale), diagnosis period and follow-up duration. Because of gradual implementation of the screening program in the Netherlands, we defined two periods based on year of DCIS diagnosis: 1989-1998 (gradual implementation of screening) and 1999-2004 (full coverage of screening).

Results

With a median follow-up of 10.5 years (interquartile range 7.7-14.0 years) 366 ipsilateral (screen-detected DCIS n=234, non-screen-detected DCIS n=132) and 380 contralateral (screen-detected DCIS n=245, non-screen-detected DCIS n=135) invasive breast cancers were diagnosed, and 1,088 of 7,106 women died (screen-detected DCIS n=603, non-screen-detected DCIS n=485). From 1989 to 2004 the number of non-screen-detected DCIS remained stable (mean 140, range 110-187 per year), whereas the number of screen-detected primary pure DCIS increased from 8 in 1989 to 596 in 2004. Ipsilateral invasive breast cancer risk was lower for screen-detected DCIS compared to DCIS not detected within the national screening program, irrespective of DCIS treatment, period of diagnosis, and follow-up duration (adjusted hazard ratio [HR] 0.74, 95% confidence interval [CI] 0.59-0.92, p &lt; 0.01). The prognostic value of method of detection was similar across categories of treatment, period of diagnosis, and follow-up duration. The risk of contralateral invasive breast cancer did not differ between screen-detected DCIS and non-screen-detected DCIS (adjusted HR 0.89, 95% CI 0.71-1.11, p = 0.3) and neither did all-cause mortality (adjusted HR 0.91, 95% CI 0.79-1.04, p = 0.2).

Conclusion

Women with primary pure DCIS detected through the Dutch screening program had lower risk of subsequent ipsilateral invasive breast cancer, irrespective of DCIS treatment, compared to women whose DCIS was not detected within the national screening program. However, the magnitude of this risk difference does not warrant a different treatment strategy of screen-detected DCIS as compared to non-screen-detected DCIS. Having a screen-detected DCIS was not associated with risk of subsequent contralateral invasive breast cancer and all-cause mortality.

Citation Format: Elshof LE, Schaapveld M, Schmidt MK, van Leeuwen FE, Rutgers EJTh, Wesseling J. Prognostic value of method of detection in primary pure DCIS. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-17-06.

[Pain trajectories in early symptomatic knee osteoarthritis]

DESIGN

Retrospective cohort study.

METHOD

We obtained data for this study from the 'Cohort Hip and Cohort Knee' (CHECK) study. Participants who presented with knee osteoarthritis at baseline were included. We assessed baseline patient parameters such as demographics, anamnesis and physical examination measurements. Pain outcome measure was assessed annually using a numeric rating scale. Different pain trajectories were defined by latent class growth analysis. Multinomial logistic regression was used to calculate relative risk ratios.

RESULTS

In total, 705 participants were included. Six distinct pain trajectories were identified with favourable and unfavourable courses. We found significant differences in baseline characteristics between the different pain trajectories, including BMI; symptom severity; and pain coping strategies. Higher BMI, lower education, presence of co-morbidities, higher activity limitation scores and joint space tenderness were more often associated with trajectories characterized by more pain at first presentation and pain progression. No association was found for baseline radiographic features.

CONCLUSION

We defined six distinct pain trajectories in individuals with early symptomatic knee osteoarthritis. Our results can help physicians identify those patients that require more frequent monitoring compared patients for whom a watch-and-wait policy seems justifiable. In general practice, radiography does not provide added value to the follow-up of early symptomatic knee osteoarthritis patients.

The prognostic value of the neoadjuvant response index in triple-negative breast cancer: validation and comparison with pathological complete response as outcome measure

The Neoadjuvant response index (NRI) has been proposed as a simple measure of downstaging by neoadjuvant treatment in breast cancer. It was previously found to predict recurrence-free survival (RFS) in triple-negative (TN) breast cancer. It was at least as accurate as the standard binary system, the absence or presence of a pathological complete remission (pCR), which is the commonly employed outcome measure. The NRI was evaluated in an independent consecutive series of patients to validate the previous findings. Univariable and multivariable analyses were done to assess the predictive value of clinical parameters and of the NRI for RFS. We combined the original and validation series of patients to build a multivariable predictive model for RFS after neoadjuvant chemotherapy in TN breast cancer. The validation set (N = 108) confirmed that patients with a higher-than-median NRI (>0.7) had excellent RFS (P = 0.002), similar to that of patients who had achieved a pCR. Multivariable analysis in 191 patients showed that the NRI was a strong independent predictor of RFS (P = 0.0002), with N-stage (P = 0.001) and T-stage (P = 0.014) ranking second and third, respectively. Importantly, among patients who did not achieve a pCR (NRI values below 1), higher NRI values were still associated with better RFS. The NRI is a simple method and a practical tool to predict RFS in TN breast cancer patients treated with neoadjuvant chemotherapy. It adds prognostic information to the presence or absence of pCR and could be useful to compare the efficacies of different chemotherapy regimens.

Fat/water ratios measured with diffuse reflectance spectroscopy to detect breast tumor boundaries

Recognition of the tumor during breast-conserving surgery (BCS) can be very difficult and currently a robust method of margin assessment for the surgical setting is not available. As a result, tumor-positive margins, which require additional treatment, are not found until histopathologic evaluation. With diffuse reflectance spectroscopy (DRS), tissue can be characterized during surgery based on optical parameters that are related to the tissue morphology and composition. Here we investigate which optical parameters are able to detect tumor in an area with a mixture of benign and tumor tissue and hence which parameters are most suitable for intra-operative margin assessment. DRS spectra (400-1600 nm) were obtained from 16 ex vivo lumpectomy specimens from benign, tumor border, and tumor tissue. One mastectomy specimen was used with a custom-made grid for validation purposes. The optical parameter related to the absorption of fat and water (F/W-ratio) in the extended near-infrared wavelength region (~1000-1600 nm) provided the best discrimination between benign and tumor sites resulting in a sensitivity and specificity of 100 % (excluding the border sites). Per patient, the scaled F/W-ratio gradually decreased from grossly benign tissue towards the tumor in 87.5 % of the specimens. In one test case, based on a predefined F/W-ratio for boundary tissue of 0.58, DRS produced a surgical resection plane that nearly overlapped with a 2-mm rim of benign tissue, 2 mm being the most widely accepted definition of a negative margin. The F/W-ratio provided excellent discrimination between sites clearly inside or outside the tumor and was able to detect the border of the tumor in one test case. This work shows the potential for DRS to guide the surgeon during BCS.