Pembrolizumab or placebo with chemoradiotherapy followed by pembrolizumab or placebo for newly diagnosed, high-risk, locally advanced cervical cancer (ENGOT-cx11/GOG-3047/KEYNOTE-A18): a randomised, double-blind, phase 3 clinical trial

BACKGROUND

Pembrolizumab has shown efficacy in persistent, recurrent, or metastatic cervical cancer. The effect of chemoradiotherapy might be enhanced by immunotherapy. In this phase 3 trial, we assessed the efficacy and safety of adding pembrolizumab to chemoradiotherapy in locally advanced cervical cancer.

METHODS

In this randomised, double-blind, placebo-controlled, phase 3 ENGOT-cx11/GOG-3047/KEYNOTE-A18 clinical trial, adults (age ≥18 years) at 176 medical centres in 30 countries with newly diagnosed, high-risk, locally advanced cervical cancer were randomly assigned (1:1) using an interactive voice-response system with integrated web response to receive 5 cycles of pembrolizumab (200 mg) or placebo every 3 weeks plus chemoradiotherapy, followed by 15 cycles of pembrolizumab (400 mg) or placebo every 6 weeks. Randomisation was stratified by planned external beam radiotherapy type (intensity-modulated radiotherapy or volumetric-modulated arc therapy vs non-intensity-modulated radiotherapy or non-volumetric-modulated arc therapy), cervical cancer stage at screening (International Federation of Gynecology and Obstetrics 2014 stage IB2-IIB node positive vs stage III-IVA), and planned total radiotherapy (external beam radiotherapy plus brachytherapy) dose (<70 Gy vs ≥70 Gy equivalent dose in 2 Gy fractions). Primary endpoints were progression-free survival per Response Evaluation Criteria in Solid Tumours version 1.1-by investigator or by histopathologic confirmation of suspected disease progression-and overall survival. Primary analysis was conducted in the intention-to-treat population, which included all randomly allocated participants. Safety was assessed in the as-treated population, which included all randomly allocated patients who received at least one dose of study treatment. This study is registered with ClinicalTrials.gov, NCT04221945, and is closed to new participants.

FINDINGS

Between June 9, 2020, and Dec 15, 2022, 1060 participants were randomly assigned to treatment, with 529 assigned to the pembrolizumab-chemoradiotherapy group and 531 to the placebo-chemoradiotherapy group. At data cutoff (Jan 9, 2023), median follow-up was 17·9 months (IQR 11·3-22·3) in both treatment groups. Median progression-free survival was not reached in either group; rates at 24 months were 68% in the pembrolizumab-chemoradiotherapy group versus 57% in the placebo-chemoradiotherapy group. The hazard ratio (HR) for disease progression or death was 0·70 (95% CI 0·55-0·89, p=0·0020), meeting the protocol-specified primary objective. Overall survival at 24 months was 87% in the pembrolizumab-chemoradiotherapy group and 81% in the placebo-chemoradiotherapy group (information fraction 42·9%). The HR for death was 0·73 (0·49-1·07); these data have not crossed the boundary of statistical significance. Grade 3 or higher adverse event rates were 75% in the pembrolizumab-chemoradiotherapy group and 69% in the placebo-chemoradiotherapy group.

INTERPRETATION

Pembrolizumab plus chemoradiotherapy significantly improved progression-free survival in patients with newly diagnosed, high-risk, locally advanced cervical cancer.

FUNDING

Merck Sharp & Dohme, a subsidiary of Merck & Co (MSD).

Retrospective Analysis of the Clinical Presentation, Treatment and Outcome of Angiosarcoma in a Sarcoma Referral Center

INTRODUCTION

Angiosarcoma (AS) is a rare subtype of soft tissue sarcoma. We performed a retrospective analysis of patient characteristics, treatments and prognostic factors in patients treated in a single sarcoma center.

METHODS

We reviewed records of patients treated between 1987 and 2018, categorized in 7 different subtypes according to tissue of origin and underlying risk factors. The Kaplan-Meier method was used to estimate overall survival (OS); the Cox proportional hazards model was used to study prognostic variables.

RESULTS

Among 134 patients, 30% had radiation-induced, 31% primary soft tissue, 24% cutaneous, 5% breast, 4% bone, 2% lymphedema-associated and 4% unknown primary AS. Key patient/disease characteristics varied between subgroups. The median OS was 22.0 months for the entire cohort, with 28.9% with a 5-year survival. Metastasis at diagnosis was seen in 23% of patients; 38% developed metachronous metastasis. Sixty-six (49%) patients received systemic therapy; common first-line treatments were doxorubicin (48%) and paclitaxel (39%), without a significant difference in OS between agents. Younger age, breast/radiation-induced AS, primary surgery and palliative chemotherapy were associated with better OS. Synchronous metastasis, soft tissue/unknown primary location correlated with poor survival.

CONCLUSION

AS is a very heterogeneous sarcoma subtype, with substantial variability in clinical presentation and survival among patient subsets. Prognosis is poor, and there is no difference in outcome comparing the 2 most frequently used chemotherapy agents in the first line, paclitaxel and doxorubicin.

Curative, Organ-Sparing, Multimodal, Perioperative Treatment of a Young Patient with a Rectoanal Inflammatory Myofibroblastic Tumor

INTRODUCTION

We report the case of a young female patient with a technically resectable, nonmetastatic, rectoanal, anaplastic lymphoma kinase gene (ALK)-translocated inflammatory myofibroblastic tumor (IMFT).

CASE PRESENTATION

The patient was successfully treated preoperatively with the tyrosine kinase inhibitor (TKI) crizotinib, to downsize the primary tumor, followed by sphincter-sparing surgery, and adjuvant radiotherapy and crizotinib. She is now in follow-up with good sphincter function and with no evidence of active disease.

CONCLUSION

Pre- and postoperative treatment administration of crizotinib can be given with curative intent to patients with locally advanced, nonmetastatic IMFTs to avoid mutilating surgery.

Germline HOXB13 mutations p.G84E and p.R217C do not confer an increased breast cancer risk

In breast cancer, high levels of homeobox protein Hox-B13 (HOXB13) have been associated with disease progression of ER-positive breast cancer patients and resistance to tamoxifen treatment. Since HOXB13 p.G84E is a prostate cancer risk allele, we evaluated the association between HOXB13 germline mutations and breast cancer risk in a previous study consisting of 3,270 familial non-BRCA1/2 breast cancer cases and 2,327 controls from the Netherlands. Although both recurrent HOXB13 mutations p.G84E and p.R217C were not associated with breast cancer risk, the risk estimation for p.R217C was not very precise. To provide more conclusive evidence regarding the role of HOXB13 in breast cancer susceptibility, we here evaluated the association between HOXB13 mutations and increased breast cancer risk within 81 studies of the international Breast Cancer Association Consortium containing 68,521 invasive breast cancer patients and 54,865 controls. Both HOXB13 p.G84E and p.R217C did not associate with the development of breast cancer in European women, neither in the overall analysis (OR = 1.035, 95% CI = 0.859-1.246, P = 0.718 and OR = 0.798, 95% CI = 0.482-1.322, P = 0.381 respectively), nor in specific high-risk subgroups or breast cancer subtypes. Thus, although involved in breast cancer progression, HOXB13 is not a material breast cancer susceptibility gene.

Genome-wide association study identifies 32 novel breast cancer susceptibility loci from overall and subtype-specific analyses

Breast cancer susceptibility variants frequently show heterogeneity in associations by tumor subtype1-3. To identify novel loci, we performed a genome-wide association study including 133,384 breast cancer cases and 113,789 controls, plus 18,908 BRCA1 mutation carriers (9,414 with breast cancer) of European ancestry, using both standard and novel methodologies that account for underlying tumor heterogeneity by estrogen receptor, progesterone receptor and human epidermal growth factor receptor 2 status and tumor grade. We identified 32 novel susceptibility loci (P < 5.0 × 10-8), 15 of which showed evidence for associations with at least one tumor feature (false discovery rate < 0.05). Five loci showed associations (P < 0.05) in opposite directions between luminal and non-luminal subtypes. In silico analyses showed that these five loci contained cell-specific enhancers that differed between normal luminal and basal mammary cells. The genetic correlations between five intrinsic-like subtypes ranged from 0.35 to 0.80. The proportion of genome-wide chip heritability explained by all known susceptibility loci was 54.2% for luminal A-like disease and 37.6% for triple-negative disease. The odds ratios of polygenic risk scores, which included 330 variants, for the highest 1% of quantiles compared with middle quantiles were 5.63 and 3.02 for luminal A-like and triple-negative disease, respectively. These findings provide an improved understanding of genetic predisposition to breast cancer subtypes and will inform the development of subtype-specific polygenic risk scores.

ENGOT-cx11/KEYNOTE-A18: A phase III, randomized, double-blind study of pembrolizumab with chemoradiotherapy in patients with high-risk locally advanced cervical cancer

TPS6096

Background: High-risk locally advanced cervical cancer has a poor prognosis, and more than half of patients recur in 2 y. External beam radiotherapy (EBRT) with concurrent chemotherapy followed by brachytherapy is the standard of care for locally advanced cervical cancer. The immunostimulatory activity of the PD-1 inhibitor pembrolizumab (pembro) may be enhanced by concurrent chemoradiotherapy (CRT). After the KEYNOTE-158 study, in which pembro showed durable antitumor activity, pembro monotherapy was approved for patients with PD-L1–positive recurrent or metastatic cervical cancer who progressed during or after chemotherapy. ENGOT-cx11/KEYNOTE-A18 (NCT04221945) is a phase III, randomized, placebo-controlled study evaluating pembro with concurrent CRT for the treatment of locally advanced cervical cancer. Methods: Approximately 980 patients with high-risk (FIGO 2014 stage IB2-IIB with node-positive disease or stage III-IVA), locally advanced, histologically confirmed cervical cancer who have not received systemic therapy, immunotherapy, definitive surgery, or radiation will be randomized 1:1 to receive either 5 cycles of pembro 200 mg every 3 wk (Q3W) + CRT followed by 15 cycles of pembro 400 mg Q6W or 5 cycles of placebo Q3W + CRT followed by 15 cycles of placebo Q6W. The CRT regimen includes 5 cycles (with optional 6th dose) of cisplatin 40 mg/m2 Q1W + EBRT followed by brachytherapy. Randomization is stratified by planned EBRT type (intensity-modulated radiotherapy [IMRT] or volumetric-modulated arc therapy [VMAT] vs non-IMRT or non-VMAT), cancer stage at screening (stage IB2-IIB vs III-IVA), and planned total radiotherapy dose. Treatment will continue until the patient has received 20 cycles of pembro (5 cycles 200 mg Q3W, 15 cycles 400 mg Q6W) vs placebo (~2 y) or until disease progression, unacceptable toxicity, or withdrawal. Primary endpoints are PFS per RECIST v1.1 by blinded independent central review and OS. Secondary endpoints are PFS at 2 y, OS at 3 y, complete response at 12 wk, ORR, PFS and OS in PD-L1–positive patients, EORTC QLQ-C30 and QLQ-CX24, and safety. Enrollment is ongoing. Clinical trial information: NCT04221945.

Abstract P3-08-31: Clinical and pathological features of invasive micropapillary carcinoma of the breast and correlation with prognosis

Background and objective: Invasive micropapillary carcinoma (IMPC) of the breast is a special variant of breast carcinoma with a unique morphology. Data about long-term outcome are conflicting and reports on stromal tumor infiltrating lymphocytes (sTILs) and their correlation with prognosis are scarce. In this retrospective cohort study we aimed to describe clinical and pathological features of IMPC, including sTILs assessment and immunohistochemistry studies, and their correlation with long-term outcome. Materials and methods: Patients with stage I-III IMPC (pure and mixed forms) who underwent upfront surgery at our institution between 2000 and 2016 were included. All patients signed informed consent. Standard clinico-pathological features and follow-up data to calculate distant relapse-free interval and breast cancer-specific survival were obtained from clinical records. Pathologic review of representative H&E-slides of the resection specimens included evaluation of sTILs and assessment of the micropapillary component. Surrogate molecular subtypes were based on receptor-status and histological grade. Using tissue microarrays we assessed by immunohistochemistry the pattern of staining of P53, and scored semi-qualitatively the expression of Bcl2, PAX8 and WT1. The association between predictors and outcome is analyzed using the Fine and Gray model, accounting for other-cause death as competing event. All tests are two-sided, assuming a 5% significance level. The sample size did not allow multivariate analysis. Results: We included 111 patients (median age 61,5 years; range 33-88). Luminal surrogate subtypes were most prevalent with 51 luminal A-like, 41 luminal B-like, 12 luminal HER2+, 5 HER2+ and 2 triple negative IMPC. 89% of patients had a T1 or T2 tumor and 50% of IMPC were poorly differentiated. Lymph node involvement was present in 59% and lymphovascular invasion in 44% of cases. Adjuvant chemotherapy, radiotherapy and endocrine therapy was administered in 47%, 87% and 90% of patients, respectively. Of all cases 59% were pure IMPC. Standard clinico-pathological features were comparable between pure and non-pure IMPC. sTILs were classified as low (&lt;30%), intermediate (30-50%) and high (&gt;50%) in 78%, 14% and 8% of specimens respectively. Comparison between surrogate subtypes showed higher sTILs (p=0.025) and a higher likelihood of aberrant P53 expression (p&lt;0.001) in HER2+ compared to luminal A-like subtype. Immunohistochemistry studies performed on 105 samples with enough material showed aberrant P53 expression in 10% and WT1 nuclear expression in 7% of cases. Pax8-staining was negative in all IMPC in this cohort. Bcl-2 expression was strongly related to all luminal subtypes (p&lt;0.03). After a median follow-up of 100 months, we observed 8 distant relapses (7,2%) and 3 breast cancer-related deaths (2,7%). All events occurred in non-pure IMPC. Surrogate subtypes for patients with distant relapses where luminal A-like in 4 patients while the other subtypes where each observed in 1 patient. Five out of eight patients with distant relapse had received prior adjuvant chemotherapy. Six had lymph node involvement. Higher median sTILs was correlated with worse distant relapse-free interval (HR=1.55; p=0.0172) and breast cancer-specific survival (HR=2.10; p&lt;0.001). Conclusions: Standard clinico-pathological features were similar in pure and non-pure IMPC. Despite high proportion of grade 3 differentiation and lymph node involvement, we observed a low rate of distant metastasis and within the pure IMPC (59% of patients), no distant relapses occurred. These findings could be explained by the high proportion of luminal-A like tumors in our cohort and need confirmation. Higher sTILs was associated with worse outcome in this IMPC cohort, confirming previously published observations.

Citation Format: Kevin Punie, Frederik Deman, Annouschka Laenen, Timothy Faes, Hans Wildiers, Ann Smeets, Ines Nevelsteen, Chantal Van Ongeval, Adinda Baten, Melissa Christiaens, Eva Oldenburger, Hilde Janssen, Caroline Weltens, Tatjana Geukens, Nynke Willers, Jan Ardui, Hava Izci, Laurence Slembrouck, Patrick Neven, Christine Desmedt, Giuseppe Floris. Clinical and pathological features of invasive micropapillary carcinoma of the breast and correlation with prognosis [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 P3-08-31.

Pooled Analysis of external-beam RADiotherapy parameters in phase II and phase III trials in radiochemotherapy in Anal Cancer (PARADAC)

PURPOSE

Concomitant external-beam radiochemotherapy (5-fluorouracil-mitomycin C) has become the standard of care in anal cancer since the '90s. A pooled analysis of individual patient data from 7 major trials was performed quantifying the effect of radiation therapy (RT)-related parameters on the outcome of patients with anal cancer.

MATERIALS AND METHODS

Pooling databases from combined modality trials, the impact of RT parameters (total dose, gap duration, OTT: overall treatment time) on outcome including locoregional failure (LRF), 5-year progression free survival (PFS) and toxicities were investigated. Individual patient data were received for 10/13 identified published studies conducted from 1987 to 2008 (n = 3031). A Cox regression model was used (landmark = 3 months after RT for first follow-up).

RESULTS

After data inspection indicating severe heterogeneity between trials, only 1343 patients from 7/10 studies received were analysed (the most recent ones, since 1994; median follow-up = 4.1 years). A higher overall 5-year LRF rate [22.8% (95% confidence interval [CI] 22.3-27.3%)] significantly correlated with longer OTT (p = 0.03), larger tumour size (p < 0.001) and male gender (p = 0.045). Although significant differences were not observed, subset analyses for LRF (dose range: 50.4-59 Gy) seemed to favour lower doses (p = 0.412), and when comparing a 2-week gap versus 3 (dose: 59.4 Gy), results suggested 3 weeks might be detrimental (p = 0.245). For a 2-week gap versus none (dose range: 55-59.4 Gy), no difference was observed (p = 0.89). Five-year PFS was 65.7% (95% CI: 62.8-68.5%). Higher PFS rates were observed in women (p < 0.001), smaller tumour sizes (p < 0.001) and shorter OTT (p = 0.025). Five-year overall survival [76.7% (95% CI: 73.9%-79.3%)] correlated positively with female gender (p < 0.001), small tumour size (p = 0.027) and short OTT (p = 0.026). Descriptive toxicity data are presented.

CONCLUSION

For patients receiving concurrent external-beam doublet chemoradiation, a longer OTT seems detrimental to outcome. Further trials involving modern techniques may better define optimal OTT and total dose.

SIOPE - Brain tumor group consensus guideline on craniospinal target volume delineation for high-precision radiotherapy

OBJECTIVE

To develop a consensus guideline for craniospinal target volume (TV) delineation in children and young adults participating in SIOPE studies in the era of high-precision radiotherapy.

METHODS AND MATERIALS

During four consensus meetings (Cambridge, Essen, Liverpool, and Marseille), conventional field-based TV has been translated into image-guided high-precision craniospinal TV by a group of expert paediatric radiation oncologists and enhanced by MRI images of liquor distribution.

RESULTS

The CTV_cranial should include the whole brain, cribriform plate, most inferior part of the temporal lobes, and the pituitary fossa. If the full length of both optic nerves is not included, the dose received by different volumes of optic nerve should be recorded to correlate with future patterns of relapse (no consensus). The CTV_cranial should be modified to include the dural cuffs of cranial nerves as they pass through the skull base foramina. Attempts to spare the cochlea by excluding CSF within the internal auditory canal should be avoided. The CTV_spinal should include the entire subarachnoid space, including nerve roots laterally. The lower limit of the spinal CTV is at the lower limit of the thecal sac, best visible on MRI scan. There is no need to include sacral root canals in the spinal CTV.

CONCLUSION

This consensus guideline has the potential to improve consistency of craniospinal TV delineation in an era of high-precision radiotherapy. This proposal will be incorporated in the RTQA guidelines of future SIOPE-BTG trials using CSI.

Quality assurance of radiotherapy in the ongoing EORTC 1219-DAHANCA-29 trial for HPV/p16 negative squamous cell carcinoma of the head and neck: Results of the benchmark case procedure

BACKGROUND AND PURPOSE

The phase III EORTC 1219-DAHANCA 29 intergroup trial evaluates the influence of nimorazole in patients with locally advanced head and neck cancer when treated with accelerated radiotherapy (RT) in combination with chemotherapy. This article describes the results of the RT Benchmark Case (BC) performed before patient inclusion.

MATERIALS AND METHODS

The participating centers were asked to perform a 2-step BC, consisting of (1) a delineation and (2) a planning exercise according to the protocol guidelines. Submissions were prospectively centrally reviewed and feedback was given to the submitting centers. Sørensen-Dice similarity index (DSI) and the 95th percentile Hausdorff distance (HD) were retrospectively used to evaluate the agreement between the centers and the expert contours.

RESULTS

Fifty-four submissions (34 delineation and 20 planning exercises) from 19 centers were reviewed. Nine (47%) centers needed to perform the delineation step twice and three (16%) centers 3 times before receiving an approval. An increase in DSI-value and a decrease in HD, in particular for the prophylactic Clinical Target Volume (pCTV), could be found for the resubmitted cases. No unacceptable variations could be found for the planning exercise.

CONCLUSIONS

These BC-results highlight the need for effective and prospective RTQA in clinical trials. Even with clearly defined protocol guidelines, delineation and not planning remain the main reason for unacceptable protocol variations. The introduction of more objective quantitative analysis methods, such as the HD and DSI, in future trials might strengthen the evaluation by experts.

Beam Output Audit results within the EORTC Radiation Oncology Group network

Beam Output Auditing (BOA) is one key process of the EORTC radiation therapy quality assurance program. Here the results obtained between 2005 and 2014 are presented and compared to previous results.

For all BOA reports the following parameters were scored: centre, country, date of audit, beam energies and treatment machines audited, auditing organisation, percentage of agreement between stated and measured dose.

Four-hundred and sixty-one BOA reports were analyzed containing the results of 1790 photon and 1366 electron beams, delivered by 755 different treatment machines. The majority of beams (91.1%) were within the optimal limit of ≤ 3%. Only 13 beams (0.4%; n = 9 electrons; n = 4 photons), were out of the range of acceptance of ≤ 5%. Previous reviews reported a much higher percentage of 2.5% or more of the BOAs with >5% deviation.

The majority of EORTC centres present beam output variations within the 3% tolerance cutoff value and only 0.4% of audited beams presented with variations of more than 5%. This is an important improvement compared to previous BOA results.

Quantification of radiation-induced lung damage with CT scans: the possible benefit for radiogenomics

BACKGROUND

Radiation-induced lung damage (RILD) is an important problem. Although physical parameters such as the mean lung dose are used in clinical practice, they are not suited for individualised radiotherapy. Objective, quantitative measurements of RILD on a continuous instead of on an ordinal, semi-quantitative, semi-subjective scale, are needed.

METHODS

Hounsfield unit (HU) changes before versus three months post-radiotherapy were correlated per voxel with the radiotherapy dose in 95 lung cancer patients. Deformable registration was used to register pre- and post-CT scans and the density increase was quantified for various dose bins. The dose-response curve for increased HU was quantified using the slope of a linear regression (HU/Gy). The end-point for the toxicity analysis was dyspnoea ≥ grade 2.

RESULTS

Radiation dose was linearly correlated with the change in HU (mean R(2) = 0.74 ± 0.28). No differences in HU/Gy between groups treated with stereotactic radiotherapy, conventional radiotherapy alone, sequential or concurrent chemo- radiotherapy were observed. In the whole patient group, 33/95 (34.7%) had dyspnoea ≥ G2. Of the 48 patients with a HU/Gy below the median, 16 (33.3%) developed dyspnoea ≥ G2, while in the 47 patients with a HU/Gy above the median, 17 (36.1%) had dyspnoea ≥ G2 (not significant). Individual patients showed a nearly 21-fold difference in radiosensitivity, with HU/Gy ranging from 0 to 10 HU/Gy.

CONCLUSIONS

HU changes identify objectively the whole range of individual radiosensitivity on a continuous, quantitative scale. CT density changes may allow more robust and accurate radiogenomics studies.

Prognostic Significance of Nodal and PgR Status on Early Relapse in Operable HER-2 Positive Breast Cancer from the Pre-Trastuzumab Era

Background: Over the last decade, trastuzumab has become a standard adjuvant treatment option in HER-2 positive breast cancers. However, with a mainly 'on-treatment' effect only, the economic burden and adverse effects incurred from its routine use for 1 year following completion of chemotherapy, there emerges a need to identify a group of HER-2 positive breast cancers at low-risk for relapse. We, therefore, investigated potential prognostic factors in a cohort of HER-2 positive breast cancers in the era before trastuzumab, especially focusing on hormonal status.Methods: We retrospectively reviewed the data of 240 trastuzumab-naïve patients with a HER-2 FISH-positive breast cancer who had primary surgery at University Hospitals Leuven between January 2000 and December 2005. We collected data including age at diagnosis, menopausal status, histologic type, tumor size, grade, lymph node involvement, estrogen receptor (ER) /progesterone receptor (PgR) status, and disease-free survival (DFS) outcome. A multivariate Cox hazard model was used to identify prognostic factors and the cumulative DFS rate was determined using the Kaplan-Meier method.Results: After a median follow-up of 57.5 months there were 50 breast cancer related events meaning that 5-year DFS rate was 78.4% for the entire cohort. Median time to first event was 20 months and ranged from 4 to 96 months. Cox model revealed that only PgR status and lymph node involvement were independent prognostic factors for disease relapse. (p = 0.03 and p &lt; 0.01 respectively). In Kaplan-Meier analysis, patients with PgR+ showed better DFS rate than those with PgR- (figure 1; 83.8% vs. 73.1%, p = 0.02) while ER status didn't reach statistical significance (p = 0.154).Nodal involvement ≥4 was strongly associated with poor DFS rate compared with node negativity. (p = 0.00). Of note, a subgroup of patients with PgR+ and LN-. presented no relapse within the first two years after surgery (figure 2).Conclusions: In this series of HER-2 positive breast cancers, PgR and nodal status were strong prognostic factors for early breast cancer relapse. Patients with a PgR+/LN- phenotype were unlikely to relapse within the first two years of surgery. We propose to evaluate the added benefit of adjuvant trastuzumab to chemotherapy in women with this phenotype as such data are yet not available from the major adjuvant trastuzumab trials.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6046.

Improving NPI for breast cancer prognosis by including PR and HER-2 expression: own data and external validation set

Abstract #1080

The Nottingham Prognostic Index (NPI) classifies primary operable breast cancer patients into good (NPI ≤ 3.4) , intermediate (NPI 3.4-5.4) and poor (NPI ≥ 5.4) prognostic risk groups [Br J Cancer 1987; 56: 489–92]. Studies indicate a significant short term prognostic role for estrogen (ER), progesterone (PR) and HER-2 receptor on disease free survival (DFS). We proposed at SABCS 2007 to add PR and HER-2 expression to the NPI called improved NPI (iNPI) defined as (NPI) + (HER-2) – (PR), with HER-2 and PR '1' in case of amplified HER-2 and any PR-expression and '0' otherwise.&#x2028; Internal validation of the iNPI was performed on 1928 breast cancer patients, primary operated between Jan 2000 and June 2005 at Univ Hospital Leuven. All patients were classified into any of the three NPI or iNPI risk group. Mean follow-up was 3.5 yrs and DFS was defined as previously stated [Breast Cancer Research and Treatment 2007; 106: S247-S247]. Out of the 601 patients classified as NPI low risk, 59 shifted towards the intermediate iNPI group. Comparison of DFS for the 59 shifted with the non-shifted patients from the low NPI class did not reveal a significant difference (p=0.129, log-rank test). 57 patients out of 935 and 136 out of 392 respectively classified as intermediate and high NPI group became high and intermediate risk according to the iNPI. In both cases, DFS of the shifted patients differed significantly from DFS of the non-shifted patients (p=&lt;.001 en p=0.029). DFS of the shifted patients with the iNPI group they where shifted to was not/marginally significant (p=0.856, p=0.462 and p=0.047 for low, intermediate and high NPI respectively).&#x2028; For external validation a dataset from the Breast Cancer Micrometastasis group in Oslo with 677 patients and known NPI, PR and HER-2 was used. Figure 1 confirms a significant difference between DFS of the shifted and the non-shifted patients within the highest NPI risk group (p=0.021). The difference in DFS between shifted and non-shifted patients was marginally non-significant (p=0.068) in the intermediate and non-significant in the low NPI group (p=0.116). The non-significant difference between DFS of the shifted groups with the DFS of the group they were shifted to was confirmed, with exception of the low NPI group (difference in systemic treatment) (p=0.040, p=0.621 and p=0.076 for low, intermediate and high NPI respectively).&#x2028; We confirm the results from an internal study at the Univ Hospital in Leuven on an external dataset. Inclusion of the PR and HER-2 status into the NPI results in more homogenate risk groups concerning DFS.&#x2028; &#x2028;

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1080.

The decrease in grip strength in aromatase inhibitor-induced arthralgia is associated with extremes in body mass index and increased tenosynovial abnormalities

Abstract #1141

Background: We previously demonstrated in 17 patients that aromatase inhibitor (AI)-induced arthralgia is associated with a decrease in grip strength corresponding to an increase in tenosynovial abnormalities on magnetic resonance imaging (MRI). It is important to identify patients at risk of developing arthralgia and its associated functional and tenosynovial changes. Reports on the effect of weight on AI-induced arthralgia are conflicting. Our purpose was to investigate the effect of body mass index (BMI) and tenosynovial abnormalities on grip strength.&#x2028; Patients and Methods: This is a prospective single-centre study including consecutive postmenopausal patients with early breast cancer receiving either tamoxifen or an AI. At baseline and after 6 months, patients filled in a rheumatologic history questionnaire and a rheumatologic examination including a grip strength test was done. At the same time points, MRI of both hands and wrists was performed. The primary endpoint was tenosynovial abnormalities from baseline on MRI. Secondary endpoints were changes from baseline for morning stiffness, grip strength and intra-articular fluid on MRI. Wilcoxon signed ranks was used to test changes from baseline and the Spearman correlation coefficient to assess the association between rheumatologic and MRI changes from baseline. Regular and robust regression analysis was employed to investigate the influence of BMI on grip strength.&#x2028; Results: Thirty three patients completed all the planned investigations and are included in this report (27 patients on AI and 6 on tamoxifen). Median age was 64 years (range 51-74) and median BMI was 24 kg/m2 (range18-45). At 6 months, patients on AI experienced increased morning stiffness (p&lt;0.05), decrease in grip strength (p&gt;0.005), increase in tenosynovial abnormalities (p&lt;0.001) and increase in intra-articular fluid (p&lt;0.001). Only minor changes were seen in patients on tamoxifen. The decrease in grip strength correlated with the tenosynovial changes on MRI (p=0.05) but was not significantly correlated with intra-articular fluid (p=0.3). The regression analysis suggests that grip strength is predicted to decrease more strongly for extremes in BMI (very high and very low BMI) and least strongly for a BMI around 25. Furthermore, the effect of tenosynovial abnormalities on decrease in grip strength does not diminish when the effect of BMI is accounted for.&#x2028; Conclusion: The functional impairment of hands in the AI-induced arthralgia is characterized by tenosynovial changes on MRI correlating with a significant decrease in hand grip strength. Grip strength is predicted to decrease more strongly for extremes in BMI and higher levels of tenosynovial abnormalities.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1141.

Biology and prognosis by age of primary operable breast cancer

Abstract #2082

Introduction Breast cancer (BC) biology and prognosis are age dependent. We studied the effect of age on BC biology, treatment and prognosis.&#x2028; Methods Data from 2059 consecutive patients, primary operated for invasive BC in UZ Leuven (01/01/00–01/06/05), were used. Patients with ≥ 3.5 yrs follow-up were included (n=1064) to study relapse in relation to age (logistic regression).&#x2028; Results Early relapse in BC is age-related, decreasing 3.2% each yr for patients &lt; 60 yrs at diagnosis (p=0.0132, 95% CI OR: 0.943-0.993). This relation is reversed &gt;60 yrs: early relapse increases 5.5% each yr (p=0.0007, 95% CI OR: 1.021-1.082). The positive lymph node status is decreasing 3.5% each yr &lt;65 yrs (p&lt;0.0001, 95% CI OR: 0.950-0.980) and increasing 3.8% each yr ≥65 yrs (p=0.0259, 95% CI OR: 1.004-1.072) (Fig 1). The chance on a positive estrogen receptor (ER) increases with increasing age until 60 yrs (p=0.0071, 95% CI OR=1.009-1.059) with no significant effect &gt;60 years. For the progesterone receptor (PR), this depends quadratically on the age at diagnosis (p=0.0108, 95% CI OR=0.999-1.000), decreasing &lt;50 years and increasing above. With increasing age, the chance on HER-2 positivity decreased (p=0.0414, 95% CI OR: 0.970-0.999). Grade 3 tumors dropped significantly until 50 yrs (p&lt;0.0001 CI OR=0.900 (0.869-0.933) whereafter we observed a non significant upward trend (Fig 2). The chance to receive any adjuvant therapy decreased with age (p=0.0023, 95% CI OR: 0.958-0.991). Above 70 yrs, systemic adjuvant therapy was absent in 12.95% of non-relapsing -, but in 28.95% of relapsing patients. Radiotherapy was not taken into account.&#x2028; Conclusion Early relapse was higher with increasing/decreasing age, starting from age 60. This goes in parallel with the U-shape curve of lymph node involvement (Fig1). Increased relapse and lymph node positivity in elderly might partially be a reflection of the fact that BC is diagnosed in a later stage in elderly patients but might also be related to different biological behavior or to decreased use of adjuvant systemic treatment. HER-2 overexpression decreases with age and age related differences in ER and PR expression as well as tumor grading are observed (Fig 2).&#x2028; &#x2028; &#x2028; &#x2028;

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2082.

Docetaxel (T) + capecitabine (X) with or without trastuzumab (H) neoadjuvant therapy for locally advanced breast cancer (BC): Phase II study

11042

Background: In MBC, adding X to T improves RR, TTP and OS; adding X to TH improves TTP. XT±H is appealing in early BC because H serum concentrations fall during the peri-operative period, potentially reducing the risk of overlapping cardiac toxicity with adjuvant anthracyclines. Methods: Pts with newly diagnosed invasive stage III inoperable BC (cT4 and/or cN2–3) received six 21d cycles of oral X 900 mg/m2 bid d1–14 + iv T 36 mg/m2 d1&8 (+ H on d1 in pts with HER2+ [IHC 3+/FISH+] tumors: 8 mg/kg cycle 1, 6 mg/kg cycles 2–6). After surgery, pts received 4–6 cycles of FEC100 and radiotherapy (+ hormone therapy and H when indicated). Clinical response was assessed after cycles 3 and 6, safety after each cycle, and pathological complete response (pCR: no residual invasive tumor in breast and axilla) after surgery. Results: 71 of 89 planned pts have completed XT±H (Table); 64 have undergone surgery (53 mastectomies, 9 wide excisions, 2 axillary lymph node dissections only). 51 pts are evaluable for safety. The most common treatment-related adverse events (AEs; G1- 2/G3) were stomatitis (61%/8%), nausea (61%/6%), diarrhea (41%/22%), fatigue (57%/4%), neuropathy (59%/0), lacrimation (57%/0) and hand- foot syndrome (33%/16%). Other G3 AEs were anorexia (14%) and vomiting (10%); neutropenic fever occurred in 4 pts (8%). 24 pts had a dose reduction for G2–3 AEs (X 47%, T 27%). 7 pts stopped therapy prematurely for AEs. No unexpected AEs occurred with anthracycline-based adjuvant therapy. Conclusions: Although all pts experienced at least one AE, toxicity was predictable and manageable with dose reduction. Based on the encouraging efficacy of XT+H in HER2+ pts, we are expanding this arm.

[Table: see text]

No significant financial relationships to disclose.

An important subgroup of phyllodes tumors of the breast is characterized by rearrangements of chromosomes 1q and 10q

From a study of 10 cases of our own and 13 cases of the literature, anomalies of chromosome 1q and 10q emerge as consistently occurring changes in an important subgroup of phyllodes tumors of the breast. Anomalies of chromosome 1 were the most frequent ones, with a gain of 1q material, and histologically the tumors in which these anomalies were found were low grade malignancies. Structural changes of 10q emerged as the second most frequent chromosome change.

[Ethical dilemmas in pediatrics: on competencies and qualifications in decision making]

In medicine medical decisions prove to be ethical issues. Whether treatment apart from being medically possible can also be meaningful, or can continue to be meaningful, is an ethical question, where interests, in nature different and sometimes contradictory, must be balanced against each other. In the department of paediatrics the doctor does not have to deal only with the patient himself, but he has also to deal with the parents, who have an interest of their own apart from the child's interest that they want to defend. A personal interpretation of standards and values can lead doctors and parents to different ways of considering the interest of the child. This can interfere with an ethically justified decision. What is essential in this discussion are the limits of everyone's proficiency, competence and responsibility. Starting from a case these notions and their implications for decisions-making will be worked out.