Abstract P4-01-15: Theprevalence of estrogen receptor-1 mutation in advanced breast cancer: The estrogen receptor one study (EROS)

Background

Estrogen receptor alpha (ESRα), encoded by the estrogen receptor-1 (ESR1) gene, is expressed in approximately 70% of all breast cancers, and hormonal therapy represents a major treatment modality in ESRα-positive cancers. The most commonly used endocrine therapies inhibit ESR activity by either targeting the ESR protein itself or depriving the receptor of its ligand. Endocrine therapy has become the mainstay of prevention and treatment of ESR+ breast cancers in all stages of the disease. Furthermore, ESR status might be a strong predictor of response to endocrine therapy. About 20% of patients who present with early disease will develop resistance manifested as recurrences either during or after adjuvant endocrine treatments. While in metastatic breast cancer (MBC) patients, the resistance rate could be as high as 30%. Recent studies unveiled that these ESR1 mutations lead to constitutive activity of the ESR, meaning that the receptor is active in absence of its ligand estrogen conferring resistance against endocrine therapy.

Purpose: The goal of the present study is to determine the frequency rate of ESR1 mutations in hormone-sensitive advanced breast cancer by using digital droplet PCR (ddPCR) technique.

Materials and Methods

This retrospective study was conducted in the Multidisciplinary Breast Clinic of the Antwerp University Hospital. The seven most common ESR1mutations (c.1138G>C (p. (E380Q)), c.1610A>G (p.(Y537C)), c.1613A>G (p.(p.D538G)), c.1607T>G (p.(L536R)), c.1387T>C (p.S463R)), c.16410A>C (p.(Y537S)), c.609T>A (p.(Y537N)) were assessed in available baseline plasma samples of women with hormone sensitive progressive breast cancer. Inclusion criteria for study participation were: female, age above 18 years, breast cancer, positive ESR expression, 5 years endocrine therapy of the primary disease, disease progression under endocrine therapy. ESR mutations were analyzed in cell-free DNA (cfDNA) by using ddPCR.

Results

In EROS study, ESR1 mutations were successfully examined in cfDNA from 21 patients with advanced breast cancer. In the current study, we reported positive ESR1 mutation in 19% of patients (4/21; 95% CI, 5%-42%). The test sensitivity was lower than the targeted value <0.1% in 29% of patients (6/21). No significant statistical difference in baseline clinical characteristics was observed in patients with wild-type and mutant ESR (p>0.05). All the patients had received AI with a variable period of good response. Adjuvant endocrine therapy for primary disease was Tamoxifen (TAM) for 57% of patients (12 of 21) of whom 8 patients had received aromatase inhibitor (AI) after two years, while 43% of patients (9 of 21) had received AI as first line adjuvant hormonal therapy. However, there was no sufficient number of samples to formally analyze the clinical impact of ESR mutation on the type of endocrine therapy.

Conclusion

ESR1 mutation analysis should be considered in hormone-sensitive MBC patients to improve the therapeutic strategies in controlling ESR signaling before the occurrence of wide spread disease metastasis.

Key words: Estrogen receptor, Mutation, breast cancer, hormonal therapy, and metastasis.

Citation Format: Najim O, Huizing M, Tjalma W. Theprevalence of estrogen receptor-1 mutation in advanced breast cancer: The estrogen receptor one study (EROS) [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 P4-01-15.

VALHUDES: A protocol for validation of human papillomavirus assays and collection devices for HPV testing on self-samples and urine samples

BACK GROUND

Systematic reviews have concluded that hrHPV DNA testing using target-amplification tests is as accurate on vaginal self-samples as on clinician-taken specimens for the detection of cervical precancer. However, insufficient evidence is available for specific HPV assay/self-sample device combinations.

OBJECTIVES

The VALHUDES protocol is designed as a diagnostic test accuracy study that aims to compare the clinical sensitivity and specificity of particular hrHPV assay(s) on vaginal self-samples and first-void-urine, collected in agreement with standardized protocols, with hrHPV testing on matched clinician-taken samples.

STUDY DESIGN

Five hundred enrolled women referred to a colposcopy clinic are invited to collect a first-void urine sample and one or more vaginal self-samples with particular devices before collection of a cervical sample by a clinician. Sample sets are subsequently analysed in a laboratory accredited for HPV testing. Disease verification for all enrolled patients is provided by colposcopy combined with histological assessment of biopsies.

RESULTS

A first VALHUDES study has started in Belgium in December 2017 with enrolment from four colposcopy centres. The following assays are foreseen to be evaluated: RealTime High Risk HPV assay (Abbott), cobas-4800 and -6800 (Roche), Onclarity (BD), Xpert HPV (Cepheid) and Anyplex II HPV HR (Seegene).

CONCLUSION

Given empirical evidence that the relative accuracy of HPV-testing on self- vs clinician-samples is robust across clinical settings, the VALHUDES protocol offers a framework for validation of HPV assay/self-sample device combinations that can be translated to a primary screening setting.

Abstract P2-01-02: The predictive value of sentinel node biopsy (SNB) in early breast cancer after neo-adjuvant chemotherapy (NACT): A prospective study

Background

SNB has replaced axillary lymph node dissection (ALND) in those patients (pts) with clinically node negative axilla. This has reduced the morbidity, in particular lymphedema considerable. SLN after NACT is feasible but not accurate in clinically node positive (cN1-3) pts (false negative rate around 10%). Therefore, continuous efforts have to been made in randomized prospective studies to improve the detetion rate of SNB in order to avoid the morbidity of ALND. The purpose of this study is to determine the negative predictive value of the sentinel node in breast cancer after NACT.

Method

A single institution prospective study regarding the negative predictive value of the sentinel node in breast cancer after NACT was conducted in the Multidisciplinary Breast Clinic of the Antwerp University Hospital from 29/03/2010 untill 12-2015 (Study number: B30020108368). Inclusion criteria for study participation were: breast cancer, age above 18 years, female, tumor stages T2-T4 N0-3 or T1N1-N3. All pts were staged by a mammography, ultrasound of the axilla, MRI of the breast, 18F-fluoro-2-deoxy-glucose(18F-FDG) positron emission tomography (PET-CT) scan and bone scintigraphy. They received NACT consisting of 12 cycles of Paclitaxel or 4 cycles of Docetaxel followed by dose dense doxorubicin or epirubicin/cyclofosfamide or vice versa as a standard initial treatment. After 6 weeks a 18F-FDG PET-CT scan was performed for early tumor response evaluation. At the day of operation, all the pts had a preoperative injecting with a 99mTC-labelled nanocolloid in the peri-areolar region. A gamma detector was used to localize the SLN(s). All SLN(s) were removed and a complete ALND was performed.

Results

A total of 150 pts were enrolled in our study of which 129 were eligible for analysis. 53 pts had a positive SLN of which 32 have a positive axillary lymph nodes (ALN) (PPV 60%); 76 pts has a negative SLN of which 6 had a positive ALN (NPV 92%). The sensitivity is 84% and the specificity 76% with a false omission rate (FOR) of 8%. 45 pts had an initial clinical N0 (cN0 is defined as clinical negative and no suspect lymph nodes on ultrasound, on MRI breast and 18F-FDG-PET CT scan). 45 pts had negative SLN, with no ALN and 2 pts had a positive SNL of which 1 pts had axillary involvement (NPV 100%). The FOR of cN1: 5%, cN2: 37%, cN3 33%. A total of 22 pts out of 84 pts (26%) of which 15/49 cN1 (30%), 6/23 (26%) cN2, 1/12 (8%)have after 6 weeks of chemotherapy, 18F-FDG normalization on 18F-FDG PET-CT scan. A total of 17 pts had a negative SLN and ALN. The FOR was 0%

Conclusion

SNB after NACT in case of cN0 is very reliable with high NPV and low FOR. In case of 18F-FDG-PET CT normalization after 6 weeks of chemotherapy and a negative SLN, no ALND has to be performed.

Citation Format: Huizing M, Najim O, Dockx Y, Huyghe I, Van den Wyngaert T, van Goethem M, Verslegers I, Papadimitriou K, Altintas S, Baldewijns M, Trinh B, van Dam P, Tjalma W. The predictive value of sentinel node biopsy (SNB) in early breast cancer after neo-adjuvant chemotherapy (NACT): A prospective 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 P2-01-02.

Cross-cultural Psychometric Evaluation of the Dutch McGill-QoL Questionnaire for Breast Cancer Patients

AIM OF THE STUDY

Assessing the cross-cultural psychometric properties of the Dutch-MQoL for breast cancer patients.

METHODS

26 patients were recruited at the Antwerp University Hospital. Eligible patients filled in the MQoL on different moments in time in order to evaluate clinimetric properties. To determine the validity; MQoL was correlated to the EORTC QLQ-C30. Internal consistency was analysed using Cronbach's and test-retest reliability was determined by ICC. For statistical responsiveness, S.E.M and MDC were calculated.

RESULTS

A strong correlation was found between the 'QoL score' of the MQoL and the domain 'existential well- being' of the EORTC QLQ-C30 (r = 0.72). An excellent test-retest reliability (ICC (1,1)) was demonstrated with intraclass coefficients ranging from 0.82 to 0.92. A MDC in total score of only 1.22 (12%) was seen, needed to detect a factual change within a patients' QoL. Psychometric properties of the Dutch MQoL were found comparable to the properties of the original questionnaire.

CONCLUSION

The Dutch version of the MQoL is a valid and reliable questionnaire for breast cancer patients and shows statistical responsiveness. Due to the strong to excellent reliability, this version of the MQoL is useful in clinical as well as scientific setting.

Ductal carcinoma in situ: a disease entity that merits more recognition

Ductal carcinoma in situ (DCIS) is a non-invasive breast carcinoma that remains in the milk ducts. It is a poorly understood disease and its natural history is not well known. This is because once diagnosed, DCIS is usually treated. It is known however that ductal carcinoma is a precursor of invasive breast carcinoma, as 14-53% can become invasive over a period of 10 years, if left untreated. With increasing knowledge about the molecular biology of DCIS, more insight is given in its relation to invasive breast cancer. Diagnosis of ductal carcinoma in situ is increasing in the last few years. This is likely caused by the increased mammographic screening for breast cancer and the higher quality of mammographic images. DCIS represents about one fifth of all mammographically detected breast cancers. Risk factors for the development of ductal carcinoma in situ are: low parity, late age at first birth and menopause, and Body Mass Index. The Van Nuys Prognostic Index is a useful scoring system to grade DCIS. DCIS is graded by scoring four characteristics: patient's age, margin width, tumor size and pathological classification. It allows us to divide DCIS lesions into different groups according to risk of local recurrence: low risk, intermediate risk and high risk. Each group requires a different treatment, respectively: local excision of the tumor; local excision and radiotherapy; and mastectomy. The use of tamoxifen in the treatment of DCIS is still controversial, but research so far has encouraging results. Interesting developments have been made in the use of Her-2 pulsed dendritic cell vaccination before DCIS surgery.

Tuberculous mastitis presenting as a lump: a mimicking disease in a pregnant woman case report and review of literature

Tuberculosis (TB) of the breast is a rare entity, and can be confused with many other breast disorders, like mamma carcinoma or inflammatory breast cancer. When finding granulomatous mastitis (GM) on histology, it is important to make a differential diagnosis and seek actively for clues on the presence of tuberculosis, sarcoidosis, Wegener's granulomatosis, or idiopathic granulomatous mastitis, since treatment strategies differ and maltreatment has major implications on morbidity and mortality. An extensive clinical evaluation, laboratory work up, and imaging will lead in most cases to the right diagnosis. Anti-tuberculous therapy is the core treatment for breast TB, and surgery is indicated for extensive or persistent residual disease. Here we present a case of tuberculous mastitis and a review of literature on GM.

Current view on ductal carcinoma in situ and importance of the margin thresholds: A review

Ductal carcinoma in situ (DCIS) is a heterogeneous group of diseases that differ in biology and clinical behaviour. Until 1980, DCIS represented less than 1% of all breast cancer cases. With the increased utilization of mammography, DCIS now accounts for 15% to 25% of newly diagnosed breast cancer cases. The Van Nuys Prognostic Index (VPNI) is a commonly used tool for ductal carcinoma in situ (DCIS) treatment approach. Patient age, tumour size, tumour margins and pathological grade are used in order to stratify patients into three groups pertaining to risk of local recurrence: low-, intermediate- and high risk. Patients in the low-risk subgroup will always be treated with excision alone, while in the highest subgroup mastectomy is the safest option. Just like invasive breast cancer (IBC) there might be a curative dilemma in the intermediate-risk group. Many trials confirm that tumour margins are the most important prognostic factor of local recurrence for DCIS patients treated with breast conserving surgery alone or with breast conserving surgery plus radiotherapy. In this article we focused specifically on the literature concerning margin thresholds.

Abstract P1-01-24: Preoperative ultrasound staging of the axilla superfluous peroperative examination of the sentinel node

Background:

Axillary surgery in breast cancer is tailored. The current standard is to perform a frozen section or dep examination of the sentinel node during surgery. If the sentinel node is found positive (≥ macrometastases) a complete axilliary resection is recommended. Preoperative identification of positive nodes will lead to a further improvement of the tailored therapy.

Hypothesis:

A percentage of less than 5% of patients who would needed an additional operation is considered acceptable.

Material and Method:

From 2010 – 2012 all breast cancer patients of the Multidisciplinary Breast Clinic Antwerpen had an ultrasound evaluation of the axilla as part of their staging.

Fine needle aspiration cytology was performed of suspicious lymph nodes. If this showed to be positive, sentinel node biopsy was bypassed. Patients with normal nodes or benign/non diagnostic biopsy had removal of the sentinel node(s) without peroperative pathological examinations.

Results:

A total of 275 breast patients had an ultrasound staging (table 1). The sensitivity, specificity, positive predictive value and negative predictive value was respectively 90%, 85%, 77% and 94%.

Table 1: Ultrasound stagingEchoLN +LN -N1 (n = 117)9027N0 (n = 158)10148

Ten of the 275 patients (3.6%) needed an axillary clearance as a second procedure.

Discussion

Preoperative detection of invaded lymph nodes has several advantages. First of all it will allow you to identify patients with positive nodes, who can participate in neoadjuvant trial. Secondly it will save operating time and avoid overloading of the system for direct examination and reduces tissue loss. This approach will reduce costs for the health system and anesthetic time for the patient, with an acceptable reoperation rate.

Conclusion

Preoperative evaluation ultrasound staging of the axillare lymph nodes will avoid peroperative examination of the sentinel node at an acceptable reoperation rate. It is better for the patient, the physicians and the health care system.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-24.

Benchmarking and audit of breast units improves quality of care

Quality Indicators (QIs) are measures of health care quality that make use of readily available hospital inpatient administrative data. Assessment quality of care can be performed on different levels: national, regional, on a hospital basis or on an individual basis. It can be a mandatory or voluntary system. In all cases development of an adequate database for data extraction, and feedback of the findings is of paramount importance. In the present paper we performed a Medline search on "QIs and breast cancer" and "benchmarking and breast cancer care", and we have added some data from personal experience. The current data clearly show that the use of QIs for breast cancer care, regular internal and external audit of performance of breast units, and benchmarking are effective to improve quality of care. Adherence to guidelines improves markedly (particularly regarding adjuvant treatment) and there are data emerging showing that this results in a better outcome. As quality assurance benefits patients, it will be a challenge for the medical and hospital community to develop affordable quality control systems, which are not leading to excessive workload.

An open-label phase II trial to assess to efficacy of sunitinib as an antieffusion agent in patients with malignant peritoneal and/or pleural effusions

e14647

Background: Pleural and peritoneal effusions are common in advanced malignant disease and relative resistant to traditional treatments. VEGF-A is considered to be a crucial factor in the biology of accumulation of malignant effusions (ME). Sunitinib is a multi-targeted TKI with a high potency of inhibiting VEGFR2. A treatment that could symptomatically reduce ME would be useful, regardless of its anti-tumoural or anti-angiogenic effect. Methods: Refractory patients with symptomatic ME were enrolled to receive 2x6 weeks of daily 37.5mg sunitinib regardless of their primary histology or site. Outcome was measured by time to re-puncture or by measurement of volume ME by CT-scan every 6 weeks or at the end of treatment. Puncture fluids and blood samples were collected for extensive biomarker analysis (VEGFA&C, VEGFR1–3, b-FGF, PDGFA-B, PDGFRα-β, PlGF1–2) on consecutive samples. Results: At present 6 patients have been enrolled. Patients had ovarian cancer (N=3), breast cancer (N=2) and squamous cervical cancer (N=1) as primary tumours. All patients had been extensively pre-treated with 4 to 8 lines of systemic therapy. Efficacy: Three (3/6) patients showed regression of effusion fluid by consecutive CT-scans. Two (2/6) patients had unchanged volume and one (1/6) patient had an increase of fluid volume. Follow-up: Two (2/6) patients stopped the trial early due to toxicity. Two patients (2/6) died during treatment due to disease progression elsewhere. Two patients (2/6) completed the 2 cycles of 6 weeks treatment. Of which, one had sustained reduction in volume fluid accumulation, while the other one had initial stabilisation after one cycle but eventually had increasing volume of ascites. Conclusions: These findings support the hypothesis that sunitinib could be useful in the management of ME. Although the numbers are low, in a majority of patients (5/6) there was reduction or stabilisation of fluid accumulation. Toxicity led to study withdrawal in a third of our patients. An update of patient numbers as well as results of translational/biomarker analysis will be presented at the meeting.

No significant financial relationships to disclose.

Angiogenic escape and tumour progression in two patients with metastatic breast cancer receiving bevacizumab treatment

Abstract #1029

Background: Vascular endothelial growth factor A (VEGF-A) has an important role in tumour progression by promoting angiogenesis. VEGF-A inhibitors, such as bevacizumab (Bev) and VEGF-Trap are being introduced into the treatment of breast cancer in order to target angiogenesis by inhibiting VEGF-A.
 Material and Methods: Two patients with metastatic breast cancer are described having tumour progression while being treated with single agent Bev. Both patients participated in the AVADO clinical phase III study, where shown to have received Bev in combination with docetaxel (D) as first line treatment for metastatic breast cancer. The first patient (A) had received 6 cycles of D and Bev and was for 4 months on single agent Bev (15mg/kg/3wk) before progressing. Pt B had received 9 cycles of D and Bev and was on 7 months of single agent Bev (15mg/kg/3wk) before disease progression. Tumour biopsies of progressing lesions were obtained after informed consent. Routine histological assessment and a CD34/Ki67 double staining were performed on their primary tumour as well as on the newly developed metastasis (A+B). Chalkley counts (CC) and endothelial cell proliferation fractions (ECP) were assessed by two independent observers. RT-PCR Taqman low density arrays with a gene panel of 94 angiogenesis related genes were performed in triplicate on both metastasis and compared to 10 other primary breast tumours.
 Results: Both lesions showed a high CC, respectively 7.5±0.62 (A) and 4.8±0.2 (B). Both lesions had elevated ECP values of 14% (A) and 8% (B).
 Using the 2 (-__CT) method and 18S as an internal control, the VEGFR1 mRNA was highly overexpressed in both A (25.18±0.12 fold change) and B (38.60±0.07 fold change) compared to the mean of 10 unselected primary breast tumours serving as controls (p<10-7). Similarly, in metastasis B, VEGF-B, TGFB1 and PDGFRA were found to be overexpressed, i.e. out of range [min-max] of the 10 primary breast tumours. A had out of range overexpression of VEGF-C. The gene expression of VEGF-A, VEGF-D, VEGFR2, VEGFR3, PDGFB and PDGFRB in both A and B were found to be in the range of the 10 controls.
 Conclusion: We describe two patients with progressive disease while being treated with Bev after an initial response on the combination of D and Bev. These new sites of disease showed a highly angiogenic and apparently vascular dependent growth pattern, in spite of high dosed anti-VEGF-A regimen. This suggests the existence of an important VEGF-A independent alternative modality of the tumour to promote angiogenesis. VEGFR1 was remarkably overexpressed in both metastases compared to controls. The expression of placental growth factor, a VEGFR1 specific ligand is further being explored. Knowledge of the biology of Bev resistance is essential since it could be useful in designing well considered combinations of targeted therapies.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1029.

Fine tuning of the Van Nuys prognostic index (VNPI) 2003 by using genomic grade index (GGI): a new tool for ductal carcinoma in situ (DCIS)

Abstract #2020

Introduction: DCIS is a heterogeneous malignant condition of the breast with no standard of care. The updated VNPI 2003 is a practical tool in treatment decision making. Recently, the introduction of GGI has been shown to be one of the most important prognostic indicators in invasive breast cancer. A GGI based on the expression of 4 genes using RT-PCR was developed and validated in invasive BC. The aim of this study was to assess its prognostic value in DCIS.
 Methods: Real Time Polymerase Chain Reaction-GGI (RT-PCR-GGI) was applied on a DCIS population. Patients were assigned into 3 subgroups according to VNPI [low risk (score 4-6), intermediate risk (score 7-9) and high risk (score 10-12)] based on nuclear grade ± necrosis, tumor size, margin width and age. The prognostic performance of GGI was assessed by replacing pathologically determined nuclear grade by GGI: VNPI-GGI. Disease free survival (DFS) was calculated by Kaplan-Meier survival plots with log-rank significance
 Results: A total of 90 patients with DCIS were analyzed. The number of recurrences per VNPI subgroup was 1/15 in subgroup 1, 5/53 in subgroup 2 and 6/22 in subgroup 3. Ten out of these 12 patients showed invasive recurrence. No statistical significance was reached (log rank 0.349; HR 3.69 [95% 0.620-21.923], p= 0.151). However, application of VNPI-GGI identified three distinct subgroups with statistically different DFS (HR = 8.887 [95% CI: 1.2–65.7], p= 0.03). Interestingly, when the VNPI-GGI was applied on the patients with low histological grade, 25% were redistributed to the high-risk group (p = 0.008). Of note, when PCR-GGI was applied to the recurrent cases (N= 12), the genomic grade status was preserved from DCIS to the recurrence disease in 83% of them.
 Conclusions: RT-PCR-GGI incorporated into the VNPI improved its prognostic value for DCIS. This method has the potential to provide a powerful tool in DCIS management. Further validation is planned in a prospective trial with a larger patient population.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2020.

Sentinel node biopsy for ipsilateral breast cancer recurrence: a review

The aim of this study was to review published reports on the feasability, results, and reliability of sentinel node biopsy in cases of ipsilateral recurrent breast cancer. A Medline search on publications from January 1999 to December 2007 and cross-references in published articles were looked for. We identified 16 reports on sentinel node biopsy in recurrent breast cancer, including a total of 287 patients. In 210/287 (73.2%) a sentinel node was identified, 77/210 (37.7%) had had previous axillary lymph node dissection and 131 (62.3%) a previous sentinel node procedure. Aberrant lymphatic drainage, other than the ipsilateral axilla was noted in 68/210 (32.4%). Of these 16/68 (23.6%) were located in the contralateral axilla. Of the removed contralateral axillary sentinel nodes 8/17 (47.1%) were invaded by cancer. We conclude that sentinel node biopsy in cases of recurrent ipsilateral breast cancer is feasible. In about one out of three cases drainage to the contralateral axilla with invasion in almost half the cases takes place. The therapeutical consequences of these findings need further study.

Neoadjuvant chemotherapy (NACT) with prolonged high-dose (HD) doxorubicin (A) and cyclophosphamide (C) with G-CSF support in locally advanced breast cancer (LABC): Long-term follow-up data

11090

Background: NACT improves survival in LABC. The optimal regimen, dose and duration is still under study Objective: To determine the efficacy and safety of prolonged preoperative HD-AC plus G-CSF. Methods: LABC patients (pts) were treated with AC for 6 cycles (Cy): Cy 1: A 90 mg/m2, C 1000 mg/m2; Cy 2–3: A 82.5 mg/m2, C 875 mg/m2; Cy 4–6: A 75mg/m2, C 750 mg/m2) with prophylactic (peg)filgastrim q3wks. In case of cardiotoxicity or poor tumor response (TR) pts switched to Docetaxel (D) 100mg/m2 q3wks. Within 5 weeks after NACT, pts underwent mastectomy with axillary lymph node dissection followed by radiotherapy. In case of positive estrogen (ER) or progesteron receptor (PgR), hormonal treatment was given for 5 yrs. Toxicity was scored weekly (NCI-CTC 2), response every 3 wks (WHO). Kaplan-Meier analysis was performed to calculate disease free survival (DFS) and overall survival (OS). Results: Between 8/1997 and 10/2003 21 pts (median age 55 years, range 22–74) were enrolled. One pt had stage IIB, 6 stage IIIA, 14 stage IIIB disease (10 T4d). 10 tumors were ER+, 5 PgR+, none overexpressed Her-2/Neu. A total of 130 NACT Cy was given. 15 pts completed all 6 AC Cy, 6 switched to D because of a decrease in left ventricular ejection fraction (LVEF? >10%, n=2) or insufficient TR (n=4). Dose reduction of AC was needed in 1 pt (last Cy), dose delays in 4 pts. Nausea and vomiting were generally mild; grade 4 anorexia occured in one pt. Grade 4 leucopenia and neutropenia in 14 and 18 pts, respectively. Neutropenic fever requiring hospitalization occurred in 5 pts, thrombocytopenia grade 4 in 7 pts and grade 3 anemia in 3 pts. Two pts developed cardiomyopathy (9.5%) < 2 years after NACT. The overall TR rate (PR and CR) was 81%, clinical CR rate 14%, pathologic CR rate 10% and 14% had minimal residual disease. Three pts showed SD and only 1 pt had PD. The median follow up of all pts was 51 months (range 9–110), 5 yrs DFS 47%, OS 56%. 5 yrs DFS and OS for pT4d pts was 50% and 56%, respectively. Conclusions: NACT with HD-AC plus G-CSF for 6 Cy in this poor risk population is active and further supports the use of prolonged preoperative CT. The routine use of D after a restricted number of AC Cy may further improve results and decrease (cardio)toxicity.

No significant financial relationships to disclose.

Management of patients with non-atypical and atypical endometrial hyperplasia with a levonorgestrel-releasing intrauterine system: Long-term follow-up

OBJECTIVES

Levonorgestrel (LNG), delivered locally into the uterine cavity has a profound effect on the endometrium. The aim of the study was to use a LNG intrauterine system to treat non-atypical and atypical endometrial hyperplasia in women and to evaluate the long-term cure (remission) rate.

METHODS

Each of the 20 women in the study, of whom eight were diagnosed with atypical hyperplasia, received a LNG-IUS, releasing 20 microg LNG/day. The study is a non-comparative study with long-term follow-up (range 14-90 months).

RESULTS

All women developed a normal endometrium, except one asymptomatic woman with atypical hyperplasia who still had focal residual non-atypical hyperplasia at 3 years follow-up in the presence of a thin (< 4 mm) endometrium.

CONCLUSION

Continuous intrauterine delivery of LNG appears to be a promising alternative to hysterectomy for the treatment of endometrial hyperplasia and could enhance the success rate when compared with other routes of progestagen administration as well as intrauterine progesterone delivery. The significant reduction of the PR expression observed during treatment with the LNG-IUS appears to be a marker for the strong antiproliferative effect of the hormone at a cellular level resulting in an inhibition of estrogen bioactivity and endometrial suppression.

Endometrial safety after 5 years of continuous combined transdermal estrogen and intrauterine levonorgestrel delivery for postmenopausal hormone substitution

OBJECTIVE

To investigate endometrial histology and thickness of the endometrium after long-term use of continuous transdermal estrogen substitution combined with intrauterine release of levonorgestrel (LNG) in postmenopausal women.

DESIGN

A 5-year non-comparative prospective clinical trial.

SUBJECTS

Out of 182 symptomatic postmenopausal women using estrogen substitution therapy (EST) combined with a novel T-shaped LNG-releasing intrauterine system (Femilis Slim LNG-IUS), to prevent endometrial proliferation and bleeding, only those women (n=102) who used two consecutive LNG-IUSs, were isolated with the aim to study the long-term effects on the endometrium. The mean age of the women was 57 years (range 47-71). The majority of women received percutaneous 17beta estradiol, 1.5mg daily, or an equivalent dose by patch or orally, on a continuous basis.

MAIN OUTCOME MEASURES

Endometrial histology and ultrasonographic evidence of endometrial suppression, after a period of approximately 5 years of use. The mean duration of use of the regimen was 70 months (range 25-98).

RESULTS

The dominant endometrial histologic picture was that of inactive endometrium characterized by glandular atrophy and stroma decidualization (Kurman classification 5b). No cases of endometrial hyperplasia were found. On transvaginal ultrasound, this corresponds with a thin endometrium (< or = 5 mm).

CONCLUSION

The results of this 5-year study in 102 postmenopausal women using EST demonstrates that the LNG-IUS effectively opposes the estrogenic effect on the endometrium resulting in strong suppression during the entire period of EST. Due to its high efficacy and absence of systemic effects on organ tissues (e.g., breasts), target delivery in the uterine cavity could be a preferred route to administer a progestagen in women using EST.

Management of recurrent cervical cancer. Review of the literature and case report

The purpose of this study is to report the use of a gemcitabine-vinorelbine-cisplatin (GVP) regimen as a successful treatment for a patient with recurrent squamous cervical cancer. The patient was initially diagnosed with a Stage IIb squamous carcinoma of the uterine cervix. A radical hysterectomy with pelvic lymphadenectomy was performed. Adjuvant radiotherapy was given. Eighteen years later, a pelvic recurrence with involvement of the pelvic sidewall was diagnosed and treated with the combination of GVP. A complete clinical and radiological response was achieved and a complete pathological response was confirmed afterwards. Currently, 67 months later, the patient is well and there are no signs of disease. We reviewed the literature concerning the staging and the chemotherapeutical and surgical treatment of recurrent cervical. Based on the recent literature, we conclude that pelvic examination, MRI, PET/CT and laparoscopy are essential in staging recurrent disease, and that laterally extended endopelvic resection (LEER) as well as pre-exenterative chemotherapy are promising novel therapeutic modalities for recurrent cervical cancer with pelvic extension in an irradiated area. In order to make recent data more transparant and practical we designed a classification and flow-chart for the management of recurrent cervical cancer.

Alterations in the p53 pathway and prognosis in advanced ovarian cancer: a multi-factorial analysis of the EORTC Gynaecological Cancer group (study 55865)

PURPOSE

The study was designed to determine independent prognostic variables in suboptimally debulked advanced ovarian cancer patients entered in the randomised phase III study EORTC 55865.

EXPERIMENTAL DESIGN

Retrospectively collected paraffin blocks from 169 patients with stages IIb-IV epithelial ovarian cancer, taken at primary debulking surgery, were analysed. All patients were treated with cyclophosphamide and cisplatin (CP), and followed up for a median of 10 years. Expression of p53, bcl-2, P21, Ki-67 and HER-2 status was assessed by immunohistochemistry (IHC).

RESULTS

Expression of p21, a downstream effector of the p53 gene, was found to be a favourable prognostic factor for survival (HR 0.58, CI 0.36-0.94, p=0.025) in addition to FIGO stage (HR 1.54, CI 1.08-2.21, p=or<0.02). For progression free survival (PFS), both p21 (HR 0.52) and Ki-67 (HR 0.6) were significant factors.

CONCLUSION

P21 overexpression is a positive prognostic factor for survival and PFS in advanced ovarian carcinoma with residual lesions of more than 1 cm.

Postpartum hemorrhage: practical approach to a life-threatening complication

Postpartum haemorrhage (PPH) occurs in 5% of all deliveries and is responsible for a major part of maternal mortality. Adequate attendance to this complication can mean the difference between life and death. A well-trained staff together with clear and simple guidelines can make a significant difference to the patient. The aim of this article is to offer a practical guide for the management of PPH; a flowchart is presented. When faced with refractory hemorrhage, one can switch to interventional therapy or surgery. Efficiency and speed play a key part in the approach to this life threatening bleeding.

Contrast-enhanced MR imaging of breast lesions and effect on treatment

PURPOSE

To assess the value of local staging with preoperative magnetic resonance imaging (MRI) in patients with suspect breast lesions and the effect on therapeutic approach.

MATERIALS AND METHODS

Two hundred and four consecutive women with suspect breast lesions on clinical examination (CE) and/or mammography (MX) and/or ultrasound (US) underwent preoperative contrast-enhanced MRI. Detection of multifocal, multicentric and bilateral breast cancer by all three imaging modalities was evaluated. Results of preoperative breast MRI were discussed with the treating surgeons. The type of therapeutic change after preoperative MRI was marked on a questionnaire (none, additional fine needle aspiration, core biopsy, open biopsy, wider excision, mastectomy) and considered 'necessary' or 'unnecessary' using final histopathological results as gold standard.

RESULTS

In 170 patients, breast cancer was diagnosed. MRI detected 96% of multifocal disease and 95% of multicentric disease, whereas MX depicted 37 and 18%, and US 41 and 9% of them, respectively. All bilateral breast cancers were seen on MRI; both MX and US detected 56%. Findings of more extensive disease and unsuspected multiple breast cancer foci identified on MRI only, changed the therapeutic approach correctly in 30.6% of breast cancer patients. Nine unnecessary wider excisions and three unnecessary FNA/core biopsies were performed because MRI overestimated the number or size of malignant lesions.

CONCLUSION

Preoperative breast MRI is an important adjunct to conventional imaging in the loco-regional staging of breast cancer and a useful tool in treatment planning.

Preoperative breast MRI in patients with invasive lobular breast cancer

To investigate the use of MRI in preoperative characterization of invasive lobular breast cancer (ILC) and in detection of multifocal/multicentric disease. We retrospectively reviewed T1-weighted FLASH 3D precontrast and postcontrast MR images together with subtraction images of 26 women with histopathologically proven invasive lobular cancer. Two experienced radiologists described tumor patterns of ILC independently. MR findings of unifocal, multifocal, single quadrant and multiquadrant disease were correlated with results of other imaging techniques and compared with histopathological findings as gold standard. Most ILC presented on MRI as a single spiculated/irregular, inhomogeneous mass (pattern 1, n=12) or as a dominant lesion surrounded by multiple small enhancing foci (pattern 2, n=8). Multiple small enhancing foci with interconnecting enhancing strands (pattern 3) and an architectural distortion (pattern 4) were both described in three cases. There was one case of a focal area of inhomogeneous enhancement (pattern 5) and one normal MR examination (pattern 6). Unifocal and multifocal lesions were identified on MRI in four patients with normal conventional imaging. In nine women, multiple additional lesions or more extensive multiquadrant disease were correctly identified only on MRI. MRI may play an important role in the evaluation of patients with ILC, which is often difficult to diagnose on clinical examination and conventional imaging and more likely occur in multiple sites and in both breasts. However, false-negative MR findings do occur in a small percentage of ILC.

Massive infarction of a recurrent phyllodes tumor of the breast: MRI-findings

We report the imaging findings in an infarcted phyllodes tumor of the breast. A 40-year-old woman presented ten months after surgery for a benign phyllodes tumour with a palpable lump under the scar. We performed clinical examination, mammography, sonography, and MRI. The radiological diagnosis was a postoperative hematoma with granulation tissue. Surgery was performed. Histological diagnosis revealed an infarcted phyllodes tumour. This case illustrates the radiological presentation of a completely infarcted phyllodes tumour. As far as we know, imaging findings of an infarcted phyllodes tumour have not been reported yet.

The correlation of preoperative CT, MR imaging, and clinical staging (FIGO) with histopathology findings in primary cervical carcinoma

The aim of this study was to compare the preoperative findings of abdominal/pelvic CT and MRI with the preoperative clinical International Federation of Obstetrics and Gynecology (FIGO) staging and postoperative pathology report in patients with primary cancer of the cervix. Thirty-six patients with surgical-pathological proven primary cancer of the cervix were retrospectively studied for preoperative staging by clinical examination, CT, and MR imaging. Studied parameters for preoperative staging were the presence of tumor, tumor extension into the parametrial tissue, pelvic wall, adjacent organs, and lymph nodes. The CT was performed in 32 patients and MRI (T1- and T2-weighted images) in 29 patients. The CT and MR staging were based on the FIGO staging system. Results were compared with histological findings. The group is consisted of stage 0 (in situ):1, Ia:1, Ib:8, IIa:2, IIb:12, IIIa:4, IVa:6, and IVb:2 patients. The overall accuracy of staging for clinical examination, CT, and MRI was 47, 53, and 86%, respectively. The MRI incorrectly staged 2 patients and did not visualize only two tumors; one was an in situ (stage-0) and one stage-Ia (microscopic) disease. The MRI is more accurate than CT and they are both superior to clinical examination in evaluating the locoregional extension and preoperative staging of primary cancer of the cervix.

Folate and Vitamin B(12) deficiency presenting as pancytopenia in pregnancy: a case report and review of the literature

We present a case of extreme pancytopenia in a 27-year-old pregnant woman. The initial picture was compatible with a severe hematological problem in the category of aplastic anemia, paroxysmal nocturnal hemoglobinuria or even acute leukemia. The further biochemical investigations revealed, however, a folate deficiency. Nowadays this is a very rare cause of pancytopenia. Next to this she also had a Vitamin B(12) deficiency due to intrinsic factor failure. The recent literature is discussed.

Congenital right-sided diaphragmatic hernia in an elderly patient. A case report

Congenital diaphragmatic hernia is a rare condition in adulthood. It is even more exceptional when located on the right side. We describe a case of right-sided congenital diaphragmatic hernia in a 74-year old woman. The diagnosis was only made when the patient developed an acute intestinal obstruction after a laparotomy for a gynaecological benign tumour. The treatment of this condition is discussed. In our opinion, in elderly, the advantages of an elective operation in asymptomatic congenital diaphragmatic hernia have to outweigh the risks of the operation. However, if the patient shows symptoms of pulmonary dysfunction or motility disorders of the gut, or even when he has to undergo a laparotomy for a different reason, we advise to repair the hernia in order to prevent complications.

The evaluation of proliferative activity in CIN III and microinvasive cervical cancer and its role in recurrence

OBJECTIVE

To evaluate the proliferation activity in CIN III lesions and Ia1 carcinoma according to the risk of recurrence.

STUDY DESIGN

The proliferation markers PCNA (proliferating cell nuclear antigen) and mitotic index were studied in 75 patients with CIN III and in 20 patients with an Ia1 squamous carcinoma of the cervix by staining representative tissue sections for the PCNA and assessing the mitotic index. Associations between the studied proliferation markers and various histopathologic characteristics as well as recurrence were assessed.

RESULTS

Three groups of PCNA were constituted: <20, 20--40, > OR =40% positive tumour nuclei, which contained, respectively, 45 (47%), 29 (31%), and 21 (22%) patients. Microinvasive carcinomas have a higher proliferation activity than CIN III (PCNA P=0.005; mitotic index P=0.094). For CIN III, there was a significantly lower risk for recurrence in the group with lower mitotic activity, compared to the group with higher mitotic activity (Kaplan-Meier: log-rank testing P=0.044). Significance was, however, not reached for the different PCNA categories (Kaplan-Meier, log-rank test P=0.068). Multiple regression analysis showed that in our population of CIN III lesions, only age of diagnosis and treatment modality were relevant (independent) prognostic indicators for recurrence.

CONCLUSIONS

In CIN III lesions there is evidence for an association between proliferation activity and the risk of recurrence. The observed crude association weakens when adjusting for age at diagnosis and treatment modality. Apparently this feature is associated with more aggressive biological behaviour and could be used to identify women who are at higher risk of recurrence.

The association between vascular endothelial growth factor, microvessel density and clinicopathological features in invasive cervical cancer

OBJECTIVE

The aim of this study was to analyse the vascular endothelial growth factor (VEGF) expression in a series of cervical carcinomas and to compare the results with the microvessel density (MVD) and clinicopathological features.

STUDY DESIGN

The immunoreactivity for VEGF was studied in 130 invasive cervical carcinomas and in 22 patients with a carcinoma in situ of the cervix. The results were compared with the MVD.

RESULTS

Staining for VEGF of less then 50% per slide occurred in 80% of the invasive carcinomas and in 82% of the in situ carcinomas. The median MVD was 261 vv/mm(2) (range: 11-1000) in the invasive group and 146 vv/mm(2) (range: 25-536) in the in situ group. Unlike the microvessel density there was no association between VEGF expression and survival. The MVD was higher in VEGF poorer (<50%) tumours (P=0.055). Beside tumour histology (P=0.012) there were no other significant relationships between the remaining histopathological findings and VEGF expression.

CONCLUSION

Tissue VEGF expression has no prognostic value in contrast with the MVD in patients with invasive cervical cancer.

Validation of nuclear texture, density, morphometry and tissue syntactic structure analysis as prognosticators of cervical carcinoma

OBJECTIVE

To evaluate the performance of karyometry and histometry in the prediction of survival, recurrence and response of early-stage invasive cervical carcinoma.

STUDY DESIGN

Nuclear morphometry, chromatin texture and tissue architecture (characterized by syntactic structure analysis) were measured using a semiautomated image analysis system on 46 cases of Feulgen-stained tissue sections. The performance of the features was compared to that of clinical features, reported to be the best prognosticators until now, such as age, lympho-vascular permeation, histologic type, stage and grade. A K nearest neighbor classifier was used for classification.

RESULTS

In the prediction of three-year survival, recurrence and response, syntactic structure analysis proved to be the best performer. Classification rates were, respectively, 100%, 94.4% and 94.5%. In all classifications, karyometric and histometric features outperformed clinical features. In general, the best performing features described differences in second-order population statistics (standard deviations).

CONCLUSION

The results show that a quantitative analysis based on nuclear morphology, chromatin texture and histology can be considered an excellent aid in the prognosis of invasive cervical carcinoma. The measurements are not hampered by the need to undertake complete resections and are suited to daily practice when implemented in a semiautomated image analysis system.

Interval debulking surgery: an alternative for primary surgical debulking?

Retrospective analyses suggest that a subgroup of patients with Stage III and IV ovarian carcinoma can be treated with neo-adjuvant chemotherapy followed by interval debulking surgery. The absolute indications for neo-adjuvant chemotherapy appear to be Stage IV disease (excluding pleural fluid) or metastases of more than 1 g at sites where resection is impossible. In patients with an estimated total metastatic tumor load of >100 g, the presence of at least two of the following relative indications for neo-adjuvant chemotherapy are considered to be necessary: 1) uncountable (>100) peritoneal metastases, 2) estimated metastatic tumor load of >1000 g, 3) presence of large (>10 g) peritoneal metastatic plaques, 4) large volume ascites, and 5) World Health Organization (WHO) status II or III. Interval debulking surgery in patients with suboptimal primary debulking surgery has been proven effective in increasing overall survival and progression-free survival in a large prospective, randomized trial of the European Organization for Research and Treatment of Cancer (EORTC). The strategy of neo-adjuvant chemotherapy, followed by interval debulking surgery, should be confirmed in a prospective randomized trial. The EORTC 55971 trial is currently addressing this issue. We will review the studies on primary chemotherapy, interval debulking surgery, and the indications for primary chemotherapy followed by interval debulking surgery, and ongoing trials.

Neoadjuvant chemotherapy versus primary debulking surgery in advanced ovarian cancer

Primary surgical cytoreduction followed by chemotherapy usually is the preferred management of advanced (stage III or IV) ovarian cancer. The presence of residual disease after surgery is one of the most important adverse prognostic factors for survival. Neoadjuvant chemotherapy has been proposed as an alternative approach to conventional surgery as initial management of bulky ovarian cancer, with the goal of improving surgical quality. Since 1989, we have been treating advanced epithelial ovarian cancer with neoadjuvant chemotherapy instead of primary cytoreductive surgery in approximately half of the patients with stage III-IV disease. Selection of neoadjuvant chemotherapy was based on disease-related characteristics (eg, metastatic tumor load, stage of disease, performance status). Since 1993, open laparoscopy also has been used to aid in evaluating operability. A retrospective analysis of 338 patients was conducted to compare outcomes during 1989 to 1998, when neoadjuvant chemotherapy was used, with those observed during 1980 to 1988, when all patients underwent primary cytoreductive surgery. Crude 3-year survival rates were higher and postoperative mortality rates were lower during the second time period compared with the first. Overall, the results suggest that neoadjuvant chemotherapy results in survival rates in selected patients with advanced ovarian cancer that are comparable with those associated with primary cytoreductive surgery. Patients with stage IV disease, total metastatic tumor load greater than 1,000 g, uncountable plaque-shaped peritoneal metastases, and/or a poor performance status are probably the best candidates for this alternative approach. A prospective randomized study of neoadjuvant chemotherapy and primary cytoreductive surgery is ongoing.

[Primary malignant melanoma of the female urethra]

Primary malignant melanomas of the urethra are extremely rare. Clinically they are usually mistaken for other malignant diseases or even benign lesions. The case of a 66-year-old woman is reported, who presented with local bleeding of the urethra. Macroscopically a polypoid tumor was seen on the meatus externus of the urethra. A biopsy was taken and the histology report revealed a malignant melanoma. There were no signs of metastases and therefore the treatment consisted of a wide local excision only. A review of literature regarding therapy and prognosis is presented.

Angiogenesis in cervical intraepithelial neoplasia and the risk of recurrence

OBJECTIVE

We sought to investigate whether angiogenesis can predict the risk of recurrence of cervical intraepithelial neoplasia after treatment.

STUDY DESIGN

Microvessel density was studied in 75 patients with grade 3 cervical intraepithelial neoplasia and in 20 patients with microinvasive squamous carcinoma (International Federation of Gynecology and Obstetrics stage IA1) of the uterine cervix by staining representative tissue sections with the specific endothelial marker anti-CD31. The microvessel density was determined with a digital image analyzer. The results were correlated with clinical and histopathologic data.

RESULTS

The mean vessel density was 264 per field (range, 86-674 per field) in grade 3 cervical intraepithelial neoplasia and 378 per field (range, 161-848 per field; P = .001) in microinvasive squamous carcinoma. Thirteen patients with grade 3 cervical intraepithelial neoplasia had recurrent cervical intraepithelial neoplasia (microvessel density, recurrent vs nonrecurrent; not significant). Multiple regression analysis in the noninvasive group confirmed that the mean vessel density (P = .121) had no prognostic value. Furthermore, it showed that the age at diagnosis (P = .011), menopausal status (P = .052), and treatment modality (P = .022) proved to be independent prognostic factors for recurrence.

CONCLUSIONS

During the progression from noninvasive to microinvasive cervical carcinoma, the microvessel density increases significantly. However, the vessel density does not predict recurrence of noninvasive lesions.