Giant mixed hemangioma of the breast: A case report with imaging findings

Hemangioma of the breast is an uncommon tumor type that is usually small, superficially located, and impalpable. The majority of cases are cavernous hemangiomas. We describe a rare case of a large, palpable mixed hemangioma of the breast which was located in the parenchymal layer, studied with magnetic resonance imaging, mammography, and sonography. Magnetic resonance imaging findings of slow and persistent enhancement from the center to periphery are useful in characterizing benign breast hemangiomas, where even the lesion presents with a suspicious shape and margin on sonography.

Long Term Effects of a Social Capital-Based Exercise Adherence Intervention for Breast Cancer Survivors With Moderate Fatigue: A Randomized Controlled Trial

OBJECTIVES

This study reports on the long-term effects of the Better Life After Cancer: Energy, Strength, and Support (BLESS) program, a 12-week social capital-based exercise adherence program for breast cancer survivors (BCS), implemented using a randomized controlled trial design. The study investigated outcomes related to cancer-related fatigue (CRF), quality of life (QOL), physical activity, depression, anxiety, sleep quality, and social capital.

METHODS

Participants who had moderate or greater CRF were randomly assigned to the intervention (n = 24), consisting of supervised and home-based exercise, or the control (n = 26), who received exercise leaflets. Generalized estimating equations models were fitted for the outcome variables. The assessment points were baseline (M1), immediately after completing the intervention at 12 weeks (M2), 1 month (M3), and 6 months post-intervention (M4).

RESULTS

A significant reduction in the total CRF score was found for both groups. We observed a significant time by group effect at M2, indicating a reduction of behavioral/severity CRF scores and a higher increase of physical activity. Also, there was an increase in the QOL score of both groups at M2, M3, and M4, compared to M1. Both groups had reduced anxiety at M3 and M4 compared to M1. The time by group effect for depression, sleep quality and social capital was not statistically significant.

CONCLUSION

This 12-week exercise adherence program improved behavioral/severity CRF and physical activity post-intervention. Both the experimental group and control group showed significant improvements in CRF, QOL, and anxiety domains compared to the baseline, which extended to 6 months post-intervention.

TRIAL REGISTRATION

Korean Clinical Research Information Service (KCT0005763).

On-treatment derived neutrophil-to-lymphocyte ratio and survival with palbociclib and endocrine treatment: analysis of a multicenter retrospective cohort and the PALOMA-2/3 study with immune correlates

BACKGROUND

Cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors have been established as a standard treatment for hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced breast cancer (ABC); however, predictive biomarkers with translational relevance have not yet been elucidated.

METHODS

Data from postmenopausal women who received the CDK4/6 inhibitor palbociclib and letrozole for HR-positive, HER2-negative ABC from tertiary referral centers were analyzed (N = 221; exploratory cohort). Pre- and on-treatment neutrophil-to-lymphocyte ratio (NLR) and derived NLR (dNLR; neutrophil/[leukocyte-neutrophil]) were correlated with survival outcomes. Data from the PALOMA-2 (NCT01740427) and PALOMA-3 studies (NCT01942135) involving patients treated with endocrine treatment with or without palbociclib were also analyzed (validation cohort). Prospectively enrolled patients (N = 20) were subjected to immunophenotyping with circulating immune cells to explore the biological implications of immune cell dynamics.

RESULTS

In the exploratory cohort, palbociclib administration significantly reduced leukocyte, neutrophil, and lymphocyte counts on day 1 of cycle 2. Although the baseline dNLR was not significantly associated with progression-free survival (PFS), higher on-treatment dNLRs were associated with worse PFS (hazard ratio = 3.337, P < 0.001). In the PALOMA-2 validation cohort, higher on-treatment dNLRs were associated with inferior PFS in patients treated with palbociclib and letrozole (hazard ratio = 1.498, P = 0.009), and reduction in the dNLR after treatment was predictive of a survival benefit (hazard ratio = 1.555, P = 0.026). On-treatment dNLRs were also predictive of PFS following palbociclib and fulvestrant treatment in the PALOMA-3 validation cohort. Using flow cytometry analysis, we found that the CDK4/6 inhibitor prevented T cell exhaustion and diminished myeloid-derived suppressor cell frequency.

CONCLUSIONS

On-treatment dNLR significantly predicted PFS in patients with HR-positive, HER2-negative ABC receiving palbociclib and endocrine treatment. Additionally, we observed putative systemic immune responses elicited by palbociclib, suggesting immunologic changes upon CDK4/6 inhibitor treatment.

Effects of a partnership-based, needs-tailored self-management support intervention for post-treatment breast cancer survivors: A randomized controlled trial

OBJECTIVE

To examine the effectiveness of partnErship-based, needs-tailored self-Management support Program fOr Women with breast cancER (EMPOWER), a partnership-based, needs-tailored, self-management (SM) support intervention designed to empower post-treatment breast cancer survivors (BCSs) and ultimately improve their health outcomes.

METHODS

This multi-center, two-armed, randomized controlled trial comprised 94 female BCSs who had completed primary cancer treatment in South Korea. Participants were randomly assigned (1:1) to the intervention group or the wait-list control group. The intervention group received a 7-week EMPOWER intervention via telephone counseling. The primary outcome was empowerment. Secondary outcomes included self-efficacy for post-treatment SM behaviors, mental adjustment, anxiety, depression, and health-related quality of life. Data were collected via a self-reported questionnaire at baseline (T0) and at 8 (T1) and 20 weeks (T2) of follow-up. Linear mixed models were used to assess group differences over time. Effective sizes were calculated using Cohen's d.

RESULTS

Retention rates were excellent (95.7% at T1; 94.7% at T2). Linear mixed model analyses revealed that the EMPOWER group showed significantly improved empowerment (mean difference 2.24, 95% CI = 0.18 to 4.29; p = 0.016) and general health perception (mean difference 3.68, 95% CI = 0.67 to 6.72; p = 0.037) compared with the control group. Time point analysis showed that several secondary outcomes significantly improved at T1, but the effects were not sustained.

CONCLUSION

EMPOWER was effective in improving empowerment and general health perception among post-treatment BCS. Further studies are needed to determine the effectiveness of the EMPOWER intervention in other cancer populations.

Risk of Lymphedema Following Contemporary Treatment for Breast Cancer: An Analysis of 7617 Consecutive Patients From a Multidisciplinary Perspective

OBJECTIVE

The aim of this study was to identify the comprehensive risk factors for lymphedema, thereby enabling a more informed multidisciplinary treatment decision-making.

SUMMARY BACKGROUND DATA

Lymphedema is a serious long-term complication in breast cancer patients post-surgery; however, the influence of multimodal therapy on its occurrence remains unclear.

METHODS

We retrospectively collected treatment-related data from 5549 breast cancer patients who underwent surgery between 2007 and 2015 at our institution. Individual radiotherapy plans were reviewed for regional nodal irradiation (RNI) field design and fractionation type. We identified lymphedema risk factors and used them to construct nomograms to predict individual risk of lymphedema. Nomograms were validated internally using 100 bootstrap samples and externally using 2 separate datasets of 1877 Asian and 191 Western patients.

RESULTS

Six hundred thirty-nine patients developed lymphedema during a median follow-up of 60 months. The 3-year lymphedema incidence was 10.5%; this rate increased with larger irradiation volumes (no RNI vs RNI excluding axilla I-II vs RNI including axilla I-II: 5.7% vs 16.8% vs 24.1%) and when using conventional fractionation instead of hypofractionation (13.5% vs 6.8%). On multivariate analysis, higher body mass index, larger number of dissected nodes, taxane-based regimen, total mastectomy, larger irradiation field, and conventional fractionation were strongly associated with lymphedema (all P < 0.001). Nomograms constructed based on these variables showed good calibration and discrimination internally (concordance index: 0.774) and externally (0.832 for Asian and 0.820 for Western patients).

CONCLUSIONS

Trimodality breast cancer treatment factors interact to promote lymphedema. Lymphedema risk can be decreased by deintensifying node dissection, chemotherapy regimen, and field and dose of radiotherapy. Deescalation strategies on a multidisciplinary basis might minimize lymphedema risk.

Genomic landscape of extraordinary responses in metastatic breast cancer

Extreme responders to anticancer therapy are rare among advanced breast cancer patients. Researchers, however, have yet to investigate treatment responses therein on the whole exome level. We performed whole exome analysis to characterize the genomic landscape of extreme responders among metastatic breast cancer patients. Clinical samples were obtained from breast cancer patients who showed exceptional responses to anti-HER2 therapy or hormonal therapy and from those who did not. Matched breast tumor tissue (somatic DNA) and blood samples (germline DNA) were collected from a total of 30 responders and 15 non-responders. Whole exome sequencing using Illumina HiSeq2500 was performed for all 45 patients (90 samples). Somatic single nucleotide variants (SNVs), indels, and copy number variants (CNVs) were identified for the genomes of each patient. Group-specific somatic variants and mutational burden were statistically analyzed. Sequencing of cancer exomes for all patients revealed 1839 somatic SNVs (1661 missense, 120 nonsense, 43 splice-site, 15 start/stop-lost) and 368 insertions/deletions (273 frameshift, 95 in-frame), with a median of 0.7 mutations per megabase (range, 0.08 to 4.2 mutations per megabase). Responders harbored a significantly lower nonsynonymous mutational burden (median, 26 vs. 59, P = 0.02) and fewer CNVs (median 13.6 vs. 97.7, P = 0.05) than non-responders. Multivariate analyses of factors influencing progression-free survival showed that a high mutational burden and visceral metastases were significantly related with disease progression. Extreme responders to treatment for metastatic breast cancer are characterized by fewer nonsynonymous mutations and CNVs.

Pre-post analysis of a social capital-based exercise adherence intervention for breast cancer survivors with moderate fatigue: a randomized controlled trial

PURPOSE

This study assessed the effectiveness of the Better Life After Cancer: Energy, Strength, and Support (BLESS) program, a 12-week social capital-based exercise adherence program for breast cancer survivors (BCS), regarding cancer-related fatigue (CRF), quality of life (QOL), physical activity, and psychosocial characteristics.

METHODS

Forty-eight BCS with moderate or high (≥ 4) CRF participated in this randomized control trial (intervention group n = 23, control group n = 25). The intervention group participated in small group sessions to activate social capital while targeting CRF in supervised physical exercises supplemented by home-based physical exercises. The control group was only given written information on exercise. A questionnaire was used to assess CRF, QOL, physical activity, depression, anxiety, sleep quality, and social capital.

RESULTS

The majority of participants had undergone surgery less than 2 years ago. After participating in BLESS, the CRF behavioral/severity domain significantly decreased (t = 2.642, p = 0.011) and physical activity significantly increased (t = - 2.049, p = 0.046) in the intervention group, in comparison with the control group; there were no significant post-intervention differences in the control group. Both groups showed improvements in sleep quality, depression, anxiety, and QOL.

CONCLUSION

The BLESS program decreased behavioral/severity in the CRF and increased physical activity after 12 weeks among BCS. Future research needs to evaluate whether the promising results on physical activity and behavioral fatigue observed in the short term will persist over time. Also, longer-term effects should be examined.

Survival Rates of Breast Cancer Patients Aged 40 to 49 Years according to Detection Modality in Korea: Screening Ultrasound versus Mammography

Objective

The aim of this study was to compare the survival rates of Korean females aged 40 to 49 years with breast cancer detected by supplemental screening ultrasound (US) or screening mammography alone.

Materials and Methods

This single-institution retrospective study included 240 patients with breast cancer (mean age, 45.1 ± 2.8 years) detected by US or mammography who had undergone breast surgery between 2003 and 2008. Medical records were reviewed for clinicopathologic characteristics and detection methods. Disease-free survival (DFS) and overall survival (OS) were compared between patients with breast cancer in the US and mammography groups using the log-rank test. Multivariable cox regression analysis was used to identify independent variables associated with DFS and OS.

Results

Among the 240 cases of breast cancer, 43 were detected by supplemental screening US and 197 by screening mammography (mean follow-up: 7.4 years, 93.3% with dense breasts). There were 19 recurrences and 16 deaths, all occurring in the mammography group. While the US group did not differ from the mammography group in tumor stage, the patients in this group were more likely to undergo breast-conserving surgery and radiation therapy than the mammography group. The US group also showed better DFS (p = 0.016); however, OS did not differ between the two groups (p = 0.058). In the multivariable analysis, the US group showed a lower risk of recurrence (hazard ratio, 0.097; 95% confidence interval, 0.001–0.705) compared to the mammography group.

Conclusion

Our study found that Korean females aged 40–49 years with US-detected breast cancer showed better DFS than those with mammography-detected breast cancer. However, there were no statistically significant differences in OS.

Conserving the lymphatics from the arm using fluorescence imaging in patients with breast cancer at high risk of postoperative lymphedema: a pilot study

Background

Postoperative lymphedema in breast cancer survivors is a serious complication that develops from axillary lymph node dissection (ALND), chemotherapy, and radiation therapy. Axillary reverse mapping (ARM) was recently introduced to reduce lymphedema. This pilot study aimed to investigate the feasibility of preserving the ARM node using fluorescence imaging for patients at high risk of lymphedema.

Methods

We prospectively screened patients with breast cancer who had pathologic node-positive disease at diagnosis and were scheduled for neoadjuvant chemotherapy (NCT). The sentinel lymph node (SLN) was identified using blue dye and radioisotope, while the ARM node was traced using indocyanine green (ICG). In cases in which SLN was negative on the intraoperative frozen section examination, the ARM node and lymphatics were preserved.

Results

Of the 20 screened patients, six whose metastatic axillary lymph node (ALN) was converted to clinically node-negative disease after NCT were enrolled. No patients experienced recurrence at 24 months postoperative. Four patients who had a preserved ARM node did not develop lymphedema. One patient whose ARM node was not preserved due to SLN identification failure did not develop postoperative lymphedema. One patient who underwent ALND without ARM node conservation because of metastatic SLN on frozen section examination developed postoperative lymphedema.

Conclusions

ARM is oncologically safe, decreases the incidence of postoperative lymphedema, and allows for the early detection of postoperative lymphedema in patients who underwent ALND. Ultimately, ARM may help improve the quality of life of patients with pathologic node-positive breast cancer.

Correction to: Palbociclib use with grade 3 neutropenia in hormone receptor-positive metastatic breast cancer

In the original publication of the article, under the Results section, subheading "Patient survival", the second sentence that reads as "The 6-month PFS was 92.4%, 81.8%, and 93.3% and the one-year PFS was 72.0%, 88.9%, and 78.9% in Groups 1-3, respectively." should read as "The 6-month PFS was 82.8%, 75.0%, and 68.0% and the one-year PFS was 77.0%, 62.0%, and 63.8% in Groups 1-3, respectively.".

Palbociclib use with grade 3 neutropenia in hormone receptor-positive metastatic breast cancer

PURPOSE

Neutropenia is the most common toxicity of CDK4/6 inhibitors, causing frequent dose interruptions. However, CDK4/6 inhibitor-induced neutropenia shows a benign clinical course in contrast to that caused by chemotherapy. Here, we investigated the safety of a new dose scheme for palbociclib, which avoids dose delays or reductions due to afebrile grade 3 neutropenia.

METHODS

A consecutive cohort of ER( +)/HER2( -) advanced breast cancer patients who received palbociclib between 2017 and 2018 was analyzed. The patients were classified into Group 1 (patients who maintained palbociclib dose with afebrile grade 3 neutropenia), Group 2 (patients who experienced any dose modification with afebrile grade 3 neutropenia), and Group 3 (patients without afebrile grade 3 neutropenia). The primary endpoint was febrile neutropenia incidence; other toxicities were compared with those of the PALOMA-2 trial.

RESULTS

Among the 107 patients, 54.2%, 22.4%, and 23.4% were classified into Groups 1, 2, and 3, respectively. There was no febrile neutropenia in Groups 1 and 2 during palbociclib treatment. Group 1 showed higher incidence of thrombocytopenia (all-grade, 32.8%; grade 3-4, 8.6%) than Group 2 and the PALOMA-2 data, but there was no bleeding related to thrombocytopenia. Group 1 showed higher incidence of all-grade non-hematologic adverse events than Group 2; only one grade 3 non-hematologic toxicity was observed in Group 1. There were no treatment-related hospitalizations or deaths in Group 1.

CONCLUSIONS

Thus, omitting palbociclib dose modification with afebrile grade 3 neutropenia is safe and tolerable without febrile neutropenia events. This scheme could be useful to avoid unnecessary reductions in palbociclib doses in future practice.

Design of a randomized controlled trial of a partnership-based, needs-tailored self-management support intervention for post-treatment breast cancer survivors

BACKGROUND

Self-management is becoming essential for breast cancer survivors, but evidence about the effectiveness of self-management support (SMS) intervention is lacking. To address this issue, we developed a theory-based SMS intervention, the 'EMPOWER', aimed at empowering breast cancer survivors. Here we describe the rationale of the intervention and its development.

METHODS

The conceptual framework of this study is the Chronic Care Model, which posits that SMS can influence patient-provider relationships and ultimately improve health outcomes. We will conduct a multi-center, 2-armed randomized controlled trial to assess the effectiveness of EMPOWER among post-treatment breast cancer survivors in South Korea. The trial will include 94 women who completed primary breast cancer treatment within the last 6 months. Participants will be randomly assigned to the intervention group or the wait-list control group (1:1). The intervention group will receive a 7-week partnership-based and needs-tailored SMS intervention via telephone counseling. The primary outcome is empowerment. The secondary outcomes include self-efficacy for post-treatment self-management behaviors, mental adjustment, psychological distress, and health-related quality of life (HRQOL). Data will be collected by self-reported questionnaire at baseline, post-intervention, and 3-month follow-up.

DISCUSSION

We believe that the EMPOWER intervention could improve HRQOL of post-treatment breast cancer survivors by enhancing their empowerment. If found successful, it could aid clinicians engaged in the long-term care of breast cancer survivors.

TRIAL REGISTRATION

Clinical Research Information Service, KCT0004794. Registered 5 March 2020.

First Experience in Korea of Stereotactic Partial Breast Irradiation for Low-Risk Early-Stage Breast Cancer

Purpose: Accelerated partial breast irradiation (A-PBI) in Korean women has been considered impracticable, owing to small breast volume and lack of high-precision radiotherapy experience. We present the first experience of stereotactic-PBI (S-PBI) with CyberKnife M6 to investigate feasibility of use and early toxicities in Korean women with early breast cancers.

Materials and Methods: A total of 104 breasts receiving S-PBI at our institution between September 2017 and October 2018 were reviewed. Patients were selected based on the American Society for Radiation Oncology (ASTRO), American Brachytherapy Society, American Society of Breast Surgeons, and Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology guidelines. A dose of 30 Gy in 5 fractions (NCT01162200) was used. Gold fiducials were routinely inserted near the tumor bed for tracking. Constraints regarding organs-at-risk followed the NSABP-B39/RTOG 0413 protocol.

Results: Median follow-up was for 13 months. Patients were categorized as “suitable” (71.2%) or “cautionary” (28.8%) according to 2017 the ASTRO guidelines. No tracking failure of inserted gold fiducials occurred. Median planning target volume (PTV) and PTV-to-whole breast volume ratio was 73.6 mL (interquartile range, 58.8–103.9 mL) and 17.0% (13.3–19.1%), respectively. Median PTV V_95%, PTV D_max, and ipsilateral breast V_50% were 97.8% (96.2–98.8%), 105.3% (104.2–106.4%), and 35.5% (28.3–39.8%), respectively. No immediate post-S-PBI toxicity ≥ grade 2 was reported, except grade 2 induration in three breasts. All patients remain disease-free to date.

Conclusion: The first use of S-PBI in Korean women was feasible and safe for selected early breast cancer. Based on these results, we have initiated a prospective study (NCT03568981) to test S-PBI in whole-breast irradiation for low-risk early breast cancer.

Coping style at diagnosis and its association with subsequent health-related quality of life in women with breast cancer: A 3-year follow-up study

PURPOSE

The aim of this study was to describe distinct coping styles of women newly diagnosed with breast cancer and to determine whether there is an association between those styles and the women's long-term health-related quality of life (HRQOL).

METHODS

Using a prospective longitudinal study design, we enrolled 101 women recently diagnosed with breast cancer in South Korea and asked them to complete a questionnaire that included the Mini-Mental Adjustment to Cancer (Mini-MAC) scale and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30).

RESULTS

From the baseline data, we identified two coping style clusters. The first ("FS cluster") had higher scores on the fighting spirit subscale and lower scores on the helpless-hopeless and anxious preoccupation subscales (n = 52, 51.5%), while the second ("HHAP cluster") scored higher on the helpless-hopeless and anxious preoccupation subscales and lower on the fighting spirit subscale (n = 49, 48.5%). In the longitudinal analysis, the FS cluster had a better HRQOL then the HHAP cluster for 2 years after diagnosis, but the HRQOLs did not differ significantly 3 years after diagnosis.

CONCLUSIONS

Maladaptive coping at diagnosis may predict poor HRQOL in women with breast cancer. Regular screening of coping style and interventions to improve poor coping style should be considered for at least 2 years post initial diagnosis.

Abstract P3-08-33: Intermediate HER2 expression predicts poor prognosis in ER (+) breast cancer patients aged 55 and older

Background The antibody-drug conjugate targeting HER2, DS8201 has shown clinical activity against breast cancer with low-level HER2 expression in early clinical trial. In this study, we investigated the clinical implication and prognostic impact of intermediate HER2 expression in the prospectively collected ER (+) early breast cancer (EBC) and metastatic breast cancer (MBC) cohorts. Methods We analyzed the prospectively collected database of EBC and MBC cohort patients in Yonsei Cancer Center. We defined patients with HER2 immunohistochemistry (IHC) 0~1+ as HER2-negative group, and IHC 2+ and in situ hybridization (ISH) negative as HER2-intermediate group. Only ER (+) patients with complete HER2 IHC and ISH status were selected, excluding HER2 IHC 3+ or ISH+ patients. A total of 2,657 early breast cancer and 535 metastatic breast cancer patients were finally analyzed. The clinical and pathological characteristics and survival outcome of the patients were compared between HER2-negative and HER2-intermediate group in each cohort. Results The 654 (24.6%) EBC patients and 166 (31.0%) MBC patients were classified as HER2-intermediate group. The HER2-intermediate patients were more common in PR negative (30.4% versus 22.6%, p&lt; 0.001) and higher nuclear grade (grade 2 or 3) patients (25.7% versus 17.4%, p = 0.001) in EBC cohort and in age ≥ 55 patients (36.7% versus 27.4%, p = 0.001) in MBC cohort. Other characteristics were not different between two groups in both cohorts. The HER2-intermediate patients showed significantly poorer recurrence-free survival (RFS) than HER2-negative patients in EBC patients (p = 0.044), although the prognostic impact was not significant in the multivariate analysis. Of note, intermediate HER2 expression was associated with significantly poorer RFS in EBC patients (p = 0.007) of age ≥ 55, but did not affect the RFS in patients of age &lt; 55. The intermediate HER2 expression independently predicted poorer RFS of EBC patients of age ≥ 55 (Hazard ratio [HR], 1.95; 95% Confidence interval [CI], 1.03-3.73; p = 0.042) in multivariate Cox regression analysis with adjustment of other prognostic factors, T stage, N stage, PR status, and histologic grade. In line with result of EBC cohort, intermediate HER2 expression was associated with poorer overall survival (OS) in MBC patients of age ≥ 55 (p = 0.037), not affecting OS in MBC patients of age &lt; 55. Intermediate HER2 expression predicted significantly poorer OS in MBC patients of age ≥ 55 (HR, 1.45; 95% CI, 1.01-2.07; p = 0.044) independent from PR status, disease status (recurrent versus de novo stage IV), and visceral metastasis. Conclusion Our analysis demonstrates intermediate HER2 expression as an independent poor prognostic factor for ER (+) breast cancer patients with age ≥ 55 in both EBC and MBC cohorts. The clinical efficacy of new HER2-targeting antibody-drug conjugates needs to be validated in this high-risk subset of ER (+) breast cancer patients.

Citation Format: Min Hwan Kim, Gun Min Kim, Jee Hung Kim, Ji Ye Kim, Hyung Seok Park, Seho Park, Young Up Cho, Byeong Woo Park, Seung Il Kim, Joo-Hyuk Sohn. Intermediate HER2 expression predicts poor prognosis in ER (+) breast cancer patients aged 55 and older [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 P3-08-33.

Intermediate HER2 expression is associated with poor prognosis in estrogen receptor-positive breast cancer patients aged 55 years and older

PURPOSE

An antibody-drug conjugate targeting HER2, DS8201, has shown clinical activity against breast cancer with low-level HER2 expression. We aimed to evaluate the prognostic impact of intermediate HER2 expression in estrogen receptor (ER)+ early breast cancer (EBC) and metastatic breast cancer (MBC) cohorts.

METHODS

We analyzed prospectively collected data from EBC and MBC cohorts at Yonsei Cancer Center. Patients with HER2 immunohistochemistry (IHC) 0 ~ 1+ were assigned to the HER2-negative group, and patients with IHC 2+ and in situ hybridization (ISH)-negativity were assigned to the HER2-intermediate group. After the exclusion of HER2 IHC 3+ or ISH+ patients, a total of 2657 EBC and 535 MBC patients were analyzed.

RESULTS

In total, 654 (24.6%) EBC and 166 (31.0%) MBC patients were classified in the HER2-intermediate group. The HER2-intermediate patients more frequently tended to have progesterone receptor (PR)-negativity and higher nuclear grade in the EBC cohort, and showed a higher proportion of patients aged ≥ 55 years compared with the HER2-negative group in the MBC cohort. The HER2-intermediate patients showed significantly poorer recurrence-free survival (RFS) compared to the HER2-negative patients in the EBC cohort (p = 0.044). Notably, intermediate HER2 expression predicted poorer RFS in EBC patients aged ≥ 55 years (hazard ratio 1.95; p = 0.042) in multivariate Cox analysis but did not affect RFS in those aged < 55 years. In line with the EBC cohort results, intermediate HER2 expression predicted poorer overall survival (OS) in MBC patients aged ≥ 55 (hazard ratio 1.45; p = 0.044) without affecting OS of those aged < 55 years.

CONCLUSION

Intermediate HER2 expression is an independent predictor of poor prognosis in both ER+ EBC and MBC patients aged ≥ 55 years. The clinical efficacy of new HER2-targeting antibody-drug conjugates needs to be validated in this high-risk subset of ER+ breast cancer patients.

An Updated Nomogram for Predicting Invasiveness in Preoperative Ductal Carcinoma In Situ of the Breast

PURPOSE

To validate and update a nomogram for predicting ductal carcinoma in situ (DCIS) upstaging in preoperative biopsy.

MATERIALS AND METHODS

Medical records of 444 preoperative DCIS patients were evaluated and used to validate a previous version of the Severance nomogram for predicting DCIS upstaging in preoperative biopsy. Patients were divided into two groups according to the final postoperative pathology. Univariate and multivariate analyses with the chi-square test, Student's t-test, and binary logistic regression method identified new significant variables. The updated nomogram was evaluated with the C-index and Hosmer-Lemeshow goodness of fit test.

RESULTS

The area under a receiver operating characteristic curve for comparison with the previous nomogram was 0.48. In postoperative pathology, the pure DCIS and invasive cancer groups comprised 345 and 99 cases, respectively. Approximately 22.3% of patients preoperatively diagnosed with DCIS were upstaged to invasive cancer. Significant variables in the univariate analysis were operation type, human epidermal growth factor receptor 2 overexpression, comedo necrosis, sonographic mass, mammographic mass, preoperative biopsy method, and suspicious microinvasion in preoperative biopsy. In multivariate analysis, operation type, sonographic mass, mammographic mass, and suspicious microinvasion were risk factors for upstaging. The updated model with these variables showed moderate discrimination and was appropriate in the calibration test.

CONCLUSION

The previous nomogram did not effectively discriminate upstaging of preoperative DCIS in an independent cohort. An updated version of the nomogram appears to provide more accurate information for predicting preoperative DCIS upstaging.

Robot-assisted Nipple-sparing Mastectomy with Immediate Breast Reconstruction: An Initial Experience

Seeking smaller and indistinct incisions, physicians have attempted endoscopic breast surgery in breast cancer patients. Unfortunately, there are some limitations in the range of movement and visualization of the operation field. Potentially addressing these limitations, we investigated the outcomes of gas and gasless robot-assisted nipple-sparing mastectomy (RANSM) with immediate breast reconstruction (IBR). Ten patients underwent 12 RANSM with IBR between November 2016 and April 2018. Patients with tumors measuring >5 cm in diameter, tumor invasion of the skin or nipple-areolar complex, proven metastatic lymph nodes, or planned radiotherapy were excluded. Age, breast weight, diagnosis, tumor size, hormone receptor status, and operation time were retrospectively collected. Postoperative outcomes including postoperative complications and final margin status of resected were analyzed. The median total operation time and console time were 351 min (267–480 min) and 51 min (18–143 min), respectively. The learning curve presented as a cumulative sum graph showed that the console time decreased and then stabilized at the eighth case. There was no open conversion or major postoperative complication. One patient had self-resolved partial nipple ischemia, and two patients experienced partial skin ischemia. We deemed that RANSM with IBR is safe and feasible for early breast cancer, benign disease of the breast, and BRCA 1/2 mutation carriers. RANSM is an advanced surgical method with a short learning curve.

Optimal treatment of pseudoangiomatous stromal hyperplasia of the breast

BACKGROUND

Pseudoangiomatous stromal hyperplasia (PASH) is a benign mesenchymal proliferative lesion of the breast. Owing to the rarity of PASH, the pathogenesis, clinical manifestation, and optimal treatment of this condition remain unclear. We aimed to clarify the appropriate management of PASH.

METHODS

We performed a retrospective analysis of the clinicopathological data of 66 cases with a diagnosis of PASH, confirmed by core needle biopsy (CNB) or surgical excision at Severance Hospital between 2000 and 2016. The primary endpoint was pathologic results after surgical excision of the lesion that confirmed PASH by CNB. The secondary endpoint was progression after the first treatment.

RESULT

The median age of patients was 41 years (range, 14-61 years). Findings on medical imaging were nonspecific. CNB was performed in 61 cases, with a diagnosis of PASH confirmed in 39 cases (63.9%). No malignant or premalignant cells directly arising from PASH were identified after surgical excision that confirmed PASH via CNB. The progression rate after the first treatment was 16.6%, with lesion size, enlargement of palpable mass size, and a diagnosis other than PASH on CNB being factors associated with progression.

CONCLUSION

CNB is sufficient to confirm PASH what is necessary for an abnormal imaging or suspicious physical examination finding. Surgical excision is not necessarily indicated to rule out occult malignancy after a diagnosis of PASH. Close monitoring or surgical excision are required to manage large lesions (>3 cm) or progressive growth of a PASH lesion.

Adjuvant chemotherapy and survival among patients 70 years of age and younger with node-negative breast cancer and the 21-gene recurrence score of 26-30

Background

The benefits of chemotherapy in node-negative, hormone receptor-positive, and human epidermal growth factor receptor 2 (HER2)-negative breast cancer patients with the 21-gene recurrence score (RS) of 18–30, particularly those with RS 26–30, are not known.

Methods

Using the Surveillance, Epidemiology, and End Results (SEER) data, we retrospectively identified 29,137 breast cancer patients with the 21-gene RS of 18–30 diagnosed between 2004 and 2015. Mortality risks according to the RS and chemotherapy use were compared by the Kaplan-Meier method and Cox’s proportional hazards model.

Results

Among the breast cancer patients with the RS 18–30, 21% of them had RS 26–30. Compared to breast cancer patients with RS 18–25, patients with RS 26–30 had more aggressive tumor characteristics and chemotherapy use and increased risk of breast cancer-specific mortality and overall mortality. In breast cancer patients who were aged ≤ 70 years and had RS of 26–30, chemotherapy administration was associated with a 32% lower risk of breast cancer-specific mortality (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.47–0.99) and a 42% lower risk of overall mortality (HR, 0.58; 95% CI, 0.44–0.76). Survival benefits were most pronounced in breast cancer patients who were younger or had grade III tumor.

Conclusions

The 21-gene RS of 18–30 showed heterogeneous outcomes, and the RS 26–30 was a significant prognostic factor for an increased risk of mortality. Adjuvant chemotherapy could improve the survival of node-negative, hormone receptor-positive, and HER2-negative breast cancer patients with the 21-gene RS 26–30 and should be considered for patients, especially younger patients or patients with high-grade tumors.

Electronic supplementary material

The online version of this article (10.1186/s13058-019-1190-4) contains supplementary material, which is available to authorized users.

Is the frozen section examination for sentinel lymph node necessary in early breast cancer patients?

Purpose

Sentinel lymph node (SLN) biopsy (SLNB) is widely performed for axillary staging in patients with breast cancer. Based on the results of frozen section examination (FSE), surgeons can decide to continue further axillary dissections. This study aimed to verify the accuracy of FSE for SLNs.

Methods

We reviewed the records of 4,219 patients who underwent SLNB for primary invasive breast cancer between 2007 and 2016 at the Severance Hospital. We evaluated factors associated with the false-negative results of FSE for SLNs using the Generalized Estimating Equations model.

Results

A total of 1,397 SLNs from 908 patients were confirmed to be metastatic. Seventy-one patients (1.7%) had confirmed pathologic N2 or N3 stage. Among metastatic SLNs, micrometastasis was found in 234 (16.8%). The overall accuracy of SLNB was 98.5%. The sensitivity and false-negative rate of FSE were 86.4% and 13.6%, respectively. Several clinicopathological factors, including the size of SLN metastases, suspicious preoperative axillary lymph nodes, and luminal B subtype, were associated with a higher rate of false-negative results.

Conclusion

Most patients were not indicated for axillary lymph node dissection. Some patients may show transition in their permanent pathology due to the size of the metastatic node. However, the false-negative results of FSE for SLNs based on the size of the metastatic node did not change our practice. Therefore, intraoperative FSE for SLN should not be routinely performed for all breast cancer patients.

Development of an exercise adherence program for breast cancer survivors with cancer-related fatigue-an intervention mapping approach

PURPOSE

Cancer-related fatigue (CRF) is the most common and distressing symptom in breast cancer survivors (BCS), with severe impact on quality of life. CRF can be reduced through exercise, but conversely, is also a barrier to exercising. The aim of this article was to apply the intervention mapping protocol (IMP) to develop an exercise adherence intervention for BCS with CRF.

METHOD

The program was developed using the IMP, which consists of six steps. Based on the data from focus group interviews and literature review, we produced a logic model of change.

RESULTS

Two performance objectives (survivors adopt and maintain exercise and survivors cope with fatigue) and 17 change objectives were generated. Also, we designed theory-based methods of change, and strategies for practical application. A structured program plan that includes intervention content and methods, ranges, and program data was proposed. Finally, an implementation and evaluation plan was developed.

CONCLUSION

The IMP provided a useful framework to systematically plan an exercise adherence program. This study resulted in a theory and practice-based exercise adherence program, based on behavioral change theories, and practice-based knowledge that fits the needs of BCS with CRF.

Abstract P3-03-31: Is sentinel lymph node biopsy necessary in all patients with early breast cancer?

Background and objectives : Since the results of the American College of Surgeons Oncology Group Z0011 published, the criteria for applying axillary lymph node (ALN) dissection was relaxed among early breast cancer patients who were scheduled for breast conserving surgery, adjuvant chemotherapy therapy, and adjuvant radiation therapy. SLNB criteria may be established if pathologic nodal status can be predicted. The aim of this study was to develop a nomogram for preoperative prediction of axillary node metastasis.

Methods: The records of 1650 patients with T1, T2 primary invasive breast cancer who were treated between January 2013 and September 2016 were selected from the medical database of Yonsei University (Seoul, South Korea). Those whom a preoperative diagnosis of axillary node metastases were excluded. Two nomogram that predicted three or more axillary metastasis and one or more axillary metastasis were developed using a binary logistic regression model with a training cohort. Internal validation was carried out adopting bootstrap method by validation cohort 500 times resampling.

Result: A total of 82 (4.8%) patients had three or more ALNs metastasis. Three hundred seventy five (17.4%) patients had one or more ALNs metastasis. Axillary metastasis was associated with Preoperative ALN suspicious image findings, clinical tumor size, Number of neoplastic foci, estrogen receptor status, Ki-67 expression, tumor marker. The nomogram was developed based on the clinical and statistically significant predictors. It had good discrimination performance (AUC 0.79, 95% CI, 0.73–0.85), (AUC 0.71, 95% CI, 0.67–0.74) and calibration fit.

Conclusion:Our nomogram might help predict the ALN metastasis in breast cancer patients. Patients with a low probability of ALN metastasis could be spared SLNB.

Citation Format: Yoon KH, Lee KB, Lee H, Lee J, Kim JY, Park HS, Park S, Kim SI, Cho YU, Park B-W. Is sentinel lymph node biopsy necessary in all patients with early breast cancer? [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 P3-03-31.

Abstract OT2-01-03: A prospective pilot study of simultaneous robotic assisted nipple sparing mastectomy and immediate reconstruction

Endoscopic breast surgery was expected to be an adequate technique to complete cancer clearance and preservation of the patient's body image. However, this technique has limitations including incomplete internal movements and unstable vision of a two dimensional camera due to inflexible endoscopic instruments especially during the skin flap formation. High resolution, ten-fold image magnification, and three-dimensional optics of robotic surgery help overcome the limitations of endoscopic surgery, and thus robotic surgery has been adopted in a wide range of intracorporeal procedures including breast surgery. However, few studies have evaluated feasibility and safety of robotic assisted nipple sparing mastectomy (RANSM) and immediate breast reconstruction (IBR) for the treatment of breast cancer. There were not any investigation to assess patients' satisfaction of cosmetic effect after performing RANSM and IBR. This study is aim to verify the feasibility and the safety of RANSM and IBR and to analyze cosmetic effect of the procedure and satisfaction of patients. The target number of enrollments is 15 patients. Patients who are diagnosed with early breast cancer or BRCA 1/2 mutation carriers are enrolled. Female patients over 20 years old who are candidates to preserve nipple areolar complex and considered to perform reconstruction with implants are prospectively collected. Written informed consents are mandatory. Patients who are considered the high possibility of postoperative radiation therapy according to preoperative stage are not included in this study. We exclude patients who want to undergo other methods of breast reconstruction than breast reconstruction with implants. Patients will undergo RANSM and IBR through a single axillary skin incision simultaneously. Regular follow-up at 1 month and 6 months after RANSM and IBR is scheduled to record recovery of a patient, amount of a drain, date of drain removal, and postoperative complications. Patient satisfaction questionnaire will be completed on the last follow-up day. To evaluate the safety of robotic assisted surgery, the oncologic safety (margin status of nipple areolar complex), postoperative recovery of a patient, and postoperative complications are investigated. We compare preoperative and postoperative 6 month photographs of patients and estimate the surgical outcome by objective indicators to evaluate the cosmetic grading by plastic surgeons. Patients' satisfaction are assessed by questionnaire (BREAST-Q) at the 6-month visit.

Citation Format: Lee J, Park HS, Kim JH, Lee DW, Song SY, Lew DH, Kim JY, Kim SI, Cho YU, Lee H, Lee KB, Yoon KH. A prospective pilot study of simultaneous robotic assisted nipple sparing mastectomy and immediate reconstruction [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-01-03.

Impact of Micrometastatic Axillary Nodes on Survival of Breast Cancer Patients with Tumors ≤2 cm

BACKGROUND

This study investigated the impact of pN1mi disease on the survival of T1 breast cancer patients and examined the clinical usefulness of the online PREDICT tool and updated staging system.

METHODS

The node stages of 2344 patients were divided into pN0, pN1mi, and pN1a. Clinicopathological parameters and survival outcomes were retrospectively analyzed. Data for 111 micrometastatic diseases were applied to the PREDICT version 2.0 and re-classified using the 8th edition of the cancer staging manual.

RESULTS

Univariable analyses demonstrated worse disease-free and overall survival rates for patients with node-positive cancer; however, the significance was not maintained in multivariable analyses. Chemotherapy improved outcomes in patients with node-positive and non-luminal A-like subtype cancers. The PREDICT tool demonstrated good performance when estimating the 5-year overall survival for pN1mi disease (area under the receiver operating characteristic curve, 0.834). According to the updated staging system, 74% of cases were down-staged to IA, and clearly splitting survival curves were identified.

CONCLUSION

pN1mi disease alone did not adversely affect survival outcomes. Biologic and treatment factors determined outcomes in cases of small-volume node micrometastasis. The PREDICT tool or new staging classification could help predict the survival of patients with micrometastatic sentinel nodes.

Prevalence of breast cancer-related risk factors in underweight premenopausal women: the Korea National Health and Nutrition Examination Survey IV-VI

PURPOSE

This study aimed to examine the prevalence and trends of breast cancer-related risk factors and characteristics in premenopausal underweight Korean women according to birth year cohort.

METHODS

Socioeconomic and breast cancer-related risk factors were investigated in 13,415 premenopausal women using nationwide cross-sectional surveys performed between 2007 and 2015. Underweight was defined as body mass index < 18.5 kg/m². Multivariable models were created using complex sample procedures.

RESULTS

Underweight women comprised 9.5% of the sample. Compared with those who were obese or of normal weight, underweight women were characterized by younger age, higher rate of metropolitan residence, higher economic status, more education, higher rates of non-manual employment and unmarried status, lower rate of early menarche, higher rates of nulliparity, lower parity, alcohol consumption, and never having breastfed, and lower levels of high physical activity. Multivariable analysis showed that underweight women had a significantly lower rate of early menarche, lower parity, higher nulliparity, older age at first delivery, and lower levels of high physical activity compared to premenopausal women with normal weight. These trends were more apparent among women born in recent years.

CONCLUSIONS

Underweight Korean premenopausal women exhibit distinctive features associated with an increased risk of breast cancer, except for a lower rate of early menarche. These associations were prominent in recent generations. Assessment of the association between underweight and premenopausal breast cancer risk should focus on promoting healthy lifestyles to reduce breast cancer risk.

BRCA1/2-negative, high-risk breast cancers (BRCAX) for Asian women: genetic susceptibility loci and their potential impacts

"BRCAX" refers breast cancers occurring in women with a family history predictive of being a BRCA1/2 mutation carrier, but BRCA1/2 genetic screening has failed to find causal mutations. In this study, we report the findings of the genetic architecture of BRCAX with novel and redefined candidate loci and their potential impacts on preventive strategy. We performed a genome-wide association study involving 1,469 BRCAX cases from the Korean Hereditary Breast Cancer study, and high-risk breast cancer cases (1,482 Asians and 9,902 Europeans) from the Breast Cancer Association Consortium. We also evaluated the previously reported susceptibility loci for their roles in the high-risk breast cancers. We have identified three novel loci (PDE7B, UBL3, and a new independent marker in CDKN2B-AS1) associated with BRCAX, and replicated previously reported SNPs (24 of 92) and moderate/high-penetrance (seven of 23) genes for Korean BRCAX. For the novel candidate loci, evidence supported their roles in regulatory function. We estimated that the common low-penetrance loci might explain a substantial part of high-risk breast cancer (39.4% for Koreans and 24.0% for Europeans). Our study findings suggest that common genetic markers with lower penetrance constitute a part of susceptibility to high-risk breast cancers, with potential implications for a more comprehensive genetic screening test.

Gasless Robot-Assisted Nipple-Sparing Mastectomy: A Case Report

Robotic surgical systems enhance surgical accuracy and efficiency by applying advanced technologies such as artificial arm joints to provide higher degrees of freedom of movement and high-quality three-dimensional images. However, the application of robotic surgical systems to breast surgery has not been widely attempted. The robotic system would improve cosmesis by enabling surgery using a single small incision. We report the first case of a gasless robot-assisted nipple-sparing mastectomy and immediate reconstruction in a patient with early breast cancer.

A Phase II Study to Evaluate the Safety and Efficacy of Pegteograstim in Korean Breast Cancer Patients Receiving Dose-Dense Doxorubicin/Cyclophosphamide

Purpose

Dose-dense chemotherapy (DD-CT) is a preferred (neo)adjuvant regimen in early breast cancer (BC). Although the results of reported randomized trials are conflicting, a recent metaanalysis showed improved overall and disease-free survival with DD-CT compared to conventional schedules. However, no DD-CT safety data for Korean BC patients are available. This phase II study was conducted to evaluate the safety and efficacy of pegteograstim in Korean BC patients receiving DD-CT.

Materials and Methods

Patients with operable (stage I-III), histologically confirmed BC received four cycles of intravenous doxorubicin (60 mg/m²) and cyclophosphamide (600 mg/m²) on day 1 every 2 weeks as neoadjuvant or adjuvant therapy. Pegteograstim (6.0 mg) was administered subcutaneously on day 2 of each cycle. The primary endpoint was the incidence of febrile neutropenia (FN). The secondary endpoints were safety and tolerability.

Results

Of 63 patients, one (1.6%) developed FN during all cycles of DD-CT. Dose delay was observed in four patients (6.3%) and dose reduction in two (3.2%) during DD-CT. Frequent adverse events (AEs) were nausea, alopecia, generalized muscle weakness, myalgia, mucositis, anorexia, dyspepsia, and diarrhea; most AEs were related to chemotherapy. Grade 3-4 AEs were reported in five of 63 patients (7.9%), and all grade 3 and 4 AEs were related to chemotherapy. Adverse drug reactions possibly linked to pegteograstim were abdominal pain, bone pain, myalgia, generalized muscle weakness, and headache in five of 63 patients (7.9%).

Conclusion

Dose-dense AC (doxorubicin/cyclophosphamide) chemotherapywith pegteograstim support is a tolerable and safe regimen in Korean early BC patients.

Abstract 1193: The impact of rapid changes in reproductive factors on the increased incidence of breast cancer in Korea

Introduction The age-standardized incidence rates of Korean breast cancer have significantly increased from 26.1 in 1999 to 63.9 in 2014, which coincides with changes in lifestyle, especially reproductive factors. We examined the contribution of temporal changes in reproductive factors to the increased incidence of breast cancer in Korea.

Methods We estimated the means of age at menarche, number of pregnancy, age at first pregnancy and duration of breastfeeding by birth cohort using the nationwide Korean National Health and Nutrition Examination Survey 2007-2015 (n=20,522 women aged between 20 and 69 years with no history of cancer). Cohorts were divided into a ten-year interval of birth year from 1940s to 1970s. Analyses took into account the complex sample design by incorporating weights, stratification and clustering. The percent increase in breast cancer incidence due to a specific factor was calculated as 100 x (RRd - 1) (RR, relative risk for a specific factor; and d, difference in the mean of a risk factor among birth cohorts).

Results Weighted proportion of birth cohorts was 12.1% in 1940s (mean age=64.9y), 24.1% in 1950s (56.1y), 31.9% in 1960s (46.8y), and 31.9% in 1970s (36.9y). We observed notable changes in reproductive factors over time: younger menarche, lower number of pregnancies, older age at first pregnancy and shorter duration of breastfeeding. A decrease in the number of pregnancies from 5.0 in 1940s to 2.7 in 1970s cohorts contributed to an 18.3% increase in breast cancer incidence. Shorter duration of lactation, earlier onset of menarche and older age at first pregnancy also contributed to 16.5%, 10.7%, and 7.1% increase in the incidence rates, respectively.

Conclusion We found that significant changes in reproductive factors in Korean women had appreciable impacts on the increase in breast cancer in Korea. Further study is warranted to evaluate the burden of breast cancer due to other modifiable risk factors such as adiposity, alcohol drinking and physical activity.

Table. Changes in risk factors by birth cohorts and their contribution to incidence changeRisk factorsBirth cohortRR (/unit)Contribution to incidence change (1940s vs. 1970s)1940s1950s1960s1970sAge at menarche (years)16.0515.4014.4613.570.9610.65%Number of pregnancy (n)4.983.923.412.660.9318.34%Age at first pregnancy (years)23.8024.5326.0627.421.1 (/5 years)7.14%Duration of breastfeeding (months)50.5327.5313.7112.830.98 (/5 months)16.54%

Citation Format: Seho Park, Hyunsoon Cho, Jee Ye Kim, Hyung Seok Park, Seung Il Kim, Young Up Cho, Byeong-Woo Park, Graham A. Colditz, Yikyung Park. The impact of rapid changes in reproductive factors on the increased incidence of breast cancer in Korea [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1193.

External validation of IBTR! 2.0 nomogram for prediction of ipsilateral breast tumor recurrence

Purpose

IBTR! 2.0 nomogram is web-based nomogram that predicts ipsilateral breast tumor recurrence (IBTR). We aimed to validate the IBTR! 2.0 using an external data set.

Materials and Methods

The cohort consisted of 2,206 patients, who received breast conserving surgery and radiation therapy from 1992 to 2012 at our institution, where wide surgical excision is been routinely performed. Discrimination and calibration were used for assessing model performance. Patients with predicted 10-year IBTR risk based on an IBTR! 2.0 nomogram score of <3%, 3%–5%, 5%–10%, and >10% were assigned to groups 1, 2, 3, and 4, respectively. We also plotted calibration values to observe the actual IBTR rate against the nomogram-derived 10-year IBTR probabilities.

Results

The median follow-up period was 73 months (range, 6 to 277 months). The area under the receiver operating characteristic curve was 0.607, showing poor accordance between the estimated and observed recurrence rate. Calibration plot confirmed that the IBTR! 2.0 nomogram predicted the 10-year IBTR risk higher than the observed IBTR rates in all groups. High discrepancies between nomogram IBTR predictions and observed IBTR rates were observed in overall risk groups. Compared with the original development dataset, our patients had fewer high grade tumors, less margin positivity, and less lymphovascular invasion, and more use of modern systemic therapies.

conclusions

IBTR! 2.0 nomogram seems to have the moderate discriminative ability with a tendency to over-estimating risk rate. Continued efforts are needed to ensure external applicability of published nomograms by validating the program using an external patient population.

Assessment of Quality of Life and Safety in Postmenopausal Breast Cancer Patients Receiving Letrozole as an Early Adjuvant Treatment

Purpose

There are few reports from Asian countries about the long-term results of aromatase inhibitor adjuvant treatment for breast cancer. This observational study aimed to evaluate the long-term effects of letrozole in postmenopausal Korean women with operable breast cancer.

Methods

Self-reported quality of life (QoL) scores were serially assessed for 3 years during adjuvant letrozole treatment using the Korean version of the Functional Assessment of Cancer Therapy-Breast questionnaires (version 3). Changes in bone mineral density (BMD) and serum cholesterol levels were also examined.

Results

All 897 patients received the documented informed consent form and completed a baseline questionnaire before treatment. Adjuvant chemotherapy was administered to 684 (76.3%) subjects, and 410 (45.7%) and 396 (44.1%) patients had stage I and II breast cancer, respectively. Each patient completed questionnaires at 3, 6, 12, 18, 24, 30, and 36 months after enrollment. Of 897 patients, 749 (83.5%) completed the study. The dropout rate was 16.5%. The serial trial outcome index, the sum of the physical and functional well-being subscales, increased gradually and significantly from baseline during letrozole treatment (p<0.001). The mean serum cholesterol level increased significantly from 199 to 205 after 36 months (p=0.042). The mean BMD significantly decreased from −0.39 at baseline to −0.87 after 36 months (p<0.001).

Conclusion

QoL gradually improved during letrozole treatment. BMD and serum cholesterol level changes were similar to those in Western countries, indicating that adjuvant letrozole treatment is well tolerated in Korean women, with minimal ethnic variation.

Association between Changes in Serum 25-Hydroxyvitamin D Levels and Survival in Patients with Breast Cancer Receiving Neoadjuvant Chemotherapy

Purpose

We investigated the changes in serum 25-hydroxyvitamin D (25[OH]D) levels before and after neoadjuvant chemotherapy (NCT) and the associations with pathologic complete response (pCR) and survival in patients with breast cancer.

Methods

Serum 25(OH)D concentrations were measured pre- and post-NCT in 374 patients between 2010 and 2013. Based on a cutoff of 20 ng/mL, patients were categorized into “either sufficient” or “both deficient” groups. The associations with clinicopathological data, including pCR and survival, were analyzed using multivariable analyses.

Results

Patients with either pre- or post-NCT sufficient 25(OH)D levels accounted for 23.8%, and the overall pCR rate was 25.9%. Most patients showed 25(OH)D deficiency at diagnosis and 65.8% showed decreased serum levels after NCT. Changes in 25(OH)D status were associated with postmenopause status, rural residence, baseline summer examination, and molecular phenotype, but not pCR. No association between survival and 25(OH)D status was found, including in the subgroup analyses based on molecular phenotypes.

Conclusion

Most Korean patients with breast cancer showed vitamin D deficiency at diagnosis and a significant decrease in the serum concentration after NCT. No association with oncologic outcomes was found. Therefore, although optimal management for vitamin D deficiency is urgent for skeletal health, further research is warranted to clearly determine the prognostic role of vitamin D in patients with breast cancer who are candidates for NCT.

A hierarchical prognostic model for risk stratification in patients with early breast cancer according to 18 F-fludeoxyglucose uptake and clinicopathological parameters

This study was to investigate a hierarchical prognostic model using clinicopathological factors and 18 F-fludeoxyglucose (FDG) uptake on positron emission tomography/computed tomography (PET/CT) for recurrence-free survival (RFS) in patients with early breast cancer who underwent surgery without neoadjuvant chemotherapy. A total of 524 patients with early breast cancer were included. The Cox proportional hazards model was used with clinicopathological variables and maximum standardized uptake value (SUVmax) on PET/CT. After classification and regression tree (CART) modeling, RFS curves were estimated using the Kaplan-Meier method and differences in each risk layer were assessed using the log-rank test. During a median follow-up of 46.2 months, 31 (5.9%) patients experienced recurrence. The CART model identified four risk layers: group 1 (SUVmax ≤6.75 and tumor size ≤2.0 cm); group 2 (SUVmax ≤6.75 and Luminal A [LumA] or TN tumor >2.0 cm); group 3 (SUVmax ≤6.75 and Luminal B [LumB] or human epidermal growth factor receptor 2 [HER2]-enriched] tumor >2.0 cm); group 4 (SUVmax >6.75). Five-year RFS was as follows: 95.9% (group 1), 98% (group 2), 82.8% (group 3), and 85.4% (group 4). Group 3 or group 4 showed worse prognosis than group 1 or group 2 (group 1 vs. group 3: P = 0.040; group 1 vs. group 4: P < 0.001; group 2 vs. group 3: P = 0.016; group 2 vs. group 4: P < 0.001). High SUVmax (>6.75) in primary breast cancer was an independent factor for poor RFS. In patients with low SUVmax, LumB or HER2-enriched tumor >2 cm was also prognostic for poor RFS, similar to high SUVmax.

Abstract OT2-01-03: A prospective randomized study comparing surgery using electrosurgical bipolar sealing devices and surgery using conventional electro-cautery

Background: Seroma and lymphorrhea are the most common complication following mastectomy and/or axillary lymph node dissection (ALND). The manifestation of seroma accelerates complications such as post-operative bleeding, wound infection, prolonged recovery period. Sealing blood vessels and lymph drainages adequately during mastectomy and/or ALND may play a main role in reducing complication. Therefore, adequate sealing vessels and lymphatics during the surgery is important to reduce seroma and lymphorrhea related complications in patients with breast cancer. Objective: This study aims to show that electrosurgical bipolar sealing device for mastectomy could provide clinical benefit in reducing seroma formation. Design: ELBCE (ELectrosurgical Bipolar Devices VS Convention Electronicautery, NCT03166384)is a prospective, randomized, two-arm assignment controlled trial of application of electrosurgical bipolar sealing device for mastectomy in patients with breast cancer. Patients is randomized in 1:1 ratio to conventional suture and tie group or electrosurgical bipolar sealing devices group. Randomization is performed using opening sealed envelope before enrollment. The primary end point is to compare the total drainage volume until drain tube removal. The time to drain removal is also measured. The secondary end points is the total amount of aspiration from seroma after drain tube removal, and the frequency of seroma aspiration. Statistical consideration: A sample size 44 subjects per each arm was planned to provide a 90% power to detect a 25% decrease of the total amount of drainage fluid after surgery by using an electrosurgical bipolar sealing device when compared to a conventional suture and tie technique. In our experience, the average total volume of fluid after conventional suture and tie technique is 220 mL, with a standard deviation of 80. Eligibility criteria:Inclusion criteria are patients older than 20 years and those who planned to undergo total mastectomy and/or ALND. Exclusion criteria are bilateral breast cancer patients, male patients, patients who underwent ipsilateral axillar surgery or radiation therapy, recurrent breast cancer patients, patients without drain catheter, and patients with ductal carcinoma in situ who have not undergone ipsilateral sentinel lymph node biopsy or ALND.Present accrual and target accrual:ELSEBA study has an accrual target of 88 patients. To date, 8 patients have been randomized. Contact information:Dr. Hyung Seek Park, E-mail: hyungseokpark.md@gmail.com; imgenius@yuhs.ac, Telephone: +82-2-2228-2100

Citation Format: Yoon KH, Park HS, Kim JH, Kim JY, Lim SM, Kim SI, Cho YU. A prospective randomized study comparing surgery using electrosurgical bipolar sealing devices and surgery using conventional electro-cautery [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-01-03.

Abstract P6-11-13: Not presented

This abstract was not presented at the symposium.

Feasibility of Charcoal Tattooing of Cytology-Proven Metastatic Axillary Lymph Node at Diagnosis and Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy in Breast Cancer Patients

Purpose

Sentinel lymph node biopsy (SLNB) can be performed when node-positive disease is converted to node-negative status after neoadjuvant chemotherapy (NCT). Tattooing nodes might improve accuracy but supportive data are limited. This study aimed to investigate the feasibility of charcoal tattooing metastatic axillary lymph node (ALN) at presentation followed by SLNB after NCT in breast cancers.

Materials and Methods

Twenty patientswith cytology-proven node metastases prospectively underwent charcoal tattooing at diagnosis. SLNB using dual tracers and axillary surgery after NCT were then performed. The detection rate of tattooed node and diagnostic performance of SLNB were analyzed.

Results

All patients underwent charcoal tattooingwithout significant morbidity. Sentinel and tattooed nodes could be detected during surgery after NCT. Nodal pathologic complete response was achieved in 10 patients. Overall sensitivity, false-negative rate (FNR), negative predictive value, and accuracy of hot/blue SLNB were 80.0%, 20.0%, 83.3%, and 90.0%, respectively. Retrieving more nodes and favorable nodal response were associated with improved performance. The best accuracy was observed when excised tattooed node was calculated together (FNR, 0.0%). Cold/non-blue tattooed nodes of five patients were removed during non-sentinel axillary surgery but clinicopathological parameters did not differ compared to patients with hot/blue tattooed node detected during SLNB, suggesting the importance of the tattooing procedure itself to improve performance.

Conclusion

Charcoal tattooing of cytology-confirmed metastatic ALN at presentation is technically feasible and does not limit SLNB after NCT. The tattooing procedure without additional preoperative localization is advantageous for improving the diagnostic performance of SLNB in this setting.

Abstract 5613: PD-1 and TIGIT are major immune checkpoint receptors expressed in breast cancer-infiltrating T cells

Immune checkpoint blockers, which target co-inhibitory receptors of T cells, have provided promising responses against various tumors. However, the expression of immune checkpoint receptors (ICRs) in breast cancer remains poorly understood. We aimed to investigate the expression pattern of multiple ICRs in tumor-infiltrating and peripheral blood (PB) lymphocytes in human breast cancer.

We isolated lymphocytes from fresh breast tumor and paired PB from 21 patients who underwent surgery between July 2016 and November 2016. Multi-color flow cytometry was performed primarily focusing on expression of multiple ICRs in CD8+ T cells and regulatory T cells (Tregs).

In CD8+ T cell subsets, PD-1+ or TIGIT+ cells were more frequently observed in tumor-infiltrating CD8+ T cells than in PB CD8+ T cells (p&lt;0.0001 and p=0.02, respectively). Around half of the tumor infiltrating CD8+ T cells expressed PD-1 (median 58.20%) and TIGIT (45.95 %). In contrast, LAG3 and TIM3 were hardly detected in both tumor-infiltrating and PB CD8+ T cells. Intriguingly, about 40% of tumor-infiltrating CD8+ T cells were PD-1+TIGIT+, and &gt;70% of PD-1+ tumor-infiltrating CD8+ T cells co-expressed TIGIT, indicating that functional exhaustion of breast tumor-infiltrating CD8+ T cells might be mediated not by PD-1 alone but by multiple receptors including TIGIT. However, the expression of PD-1 and TIGIT showed different patterns in detail. PD-1 was frequently expressed by CCR7-CD45RA- effector memory T cells (TEM) (p=0.001) whereas TIGIT was frequently expressed by CCR7-CD45RA+ effector memory RA T cells (TEMRA) (p=0.03), suggesting that TIGIT is expressed during terminal differentiation of CD8+ T cells.

Next, we examined breast tumor-infiltrating Tregs. The frequency of CD25+FoxP3+ Tregs among CD4+ T cells were higher in tumor than in PB (16.60% vs. 7.86%; p=0.002). In particular, CD45RA-FoxP3hi activated suppressive Tregs account for 77.6% of tumor-infiltrating Tregs (vs. PB 32.2%; p=0.005). Tumor-infiltrating Tregs showed higher expression of CD39 (p=0.005), a marker of the suppressive activity of Tregs. We also examined the expression of ICRs on Tregs as upregulation of these receptors is associated with enhanced suppressive activity of Tregs. CD4+CD25+FoxP3+ Tregs in tumors showed higher expression levels of PD-1, TIGIT and CTLA-4 compared to PB Tregs (p&lt;0.05).

There were no noteworthy correlations between ICR expression and clinical features, such as age, stage and subtype.

We show that PD-1 and TIGIT are major ICRs expressed in breast tumor-infiltrating CD8+ T cells. Moreover, we found that CD4+CD25+FoxP3+ Tregs are abundant in breast tumors and overexpress PD-1, TIGIT and CTLA-4. Our data provide an understanding of comprehensive phenotypes of immune checkpoint expression on T cells in breast cancer. Functional changes of CD8+ T cells and Tregs by blocking of single or multiple ICRs are being investigated.

Citation Format: Jee Ye Kim, Minsuk Kwon, Sung Mook Lim, Joo Heung Kim, Hyung Seok Park, Seho Park, Seung Il Kim, Young Up Cho, Soonmyung Paik, Eui-Cheol Shin. PD-1 and TIGIT are major immune checkpoint receptors expressed in breast cancer-infiltrating T cells [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5613. doi:10.1158/1538-7445.AM2017-5613

Clinicopathological factors increased the risk of malignancy in thyroid nodules with atypical or follicular lesions of undetermined significance (AUS/FLUS) risk factor of malignancy in thyroid nodule with AUS/FLUS

PURPOSE

Ultrasound-guided fine needle aspiration (US-FNA) in thyroid nodules is presently most commonly used to identify whether these nodules are benign or malignant. However, atypical or follicular lesions of undetermined significance (AUS/FLUS), as categorized in the Bethesda System for reporting the results of FNA, cannot be classified as benign or malignant. Therefore, several clinical factors should be considered to assess the risk of malignancy in patients with AUS/FLUS. The purpose of the present study was to determine which clinical factor increased the risk of malignancy in patients with AUS/FLUS.

METHODS

A retrospective study was done on 129 patients with fine needle aspiration categorized as AUS/FLUS from January 2011 through April 2015. Univariate and multivariate analyses were performed to assess the independent effect of risk factors such as age, sex, size of nodule, atypical descriptors, and ultrasonography criteria for malignancy.

RESULTS

We identified that the presence of spiculated margin (odds ratio [OR], 5.655; 95% confidence interval [CI], 2.114-15.131; P = 0.001), nuclear grooving (OR, 3.697; 95% CI, 1.409-9.701; P = 0.008), irregular nuclei (OR, 3.903; 95% CI, 1.442-10.560; P = 0.001) were shown to be significantly related to malignancy on univariate and multivariate analyses.

CONCLUSION

We recommend that surgical resection of thyroid nodules be considered in patients with AUS/FLUS showing the histologic findings such as nuclear grooving, irregular nuclei along with spiculated margin of ultrasonographic finding.

A proposal for a new classification of T4 breast cancer as stage IIIC: a report from the Korean Breast Cancer Society

The objective of this study is to investigate staging system of the stage IIIB and stage IIIC Breast cancer and determine the criteria for an update of the classification system. Since AJCC 6th edition, it is pointed out that stage IIIB showed a worse outcome compared with stage IIIC. Using information from two databases, including the nationwide Korean Breast Cancer Registry (KBCR), three cohorts composed of patients from the Asan Medical Center from 1989 to 2002 (cohort I), from 2003 to 2008 (cohort II), and KBCR from 2003 to 2005 (cohort III) were assembled. New classifications were suggested that rearranged stage IIIB as T1-3N3 disease and stage IIIC as T4 any N disease. From the joint analysis of 9640, invasive breast cancer patients from cohorts I and II showed the stage IIIB group showed a significantly worse DFS (HR 10.4, 95% CI 6.9-15.7) compared with the stage IIIC group (HR 7.2, 95% CI 5.9-8.7). T4d breast cancer showed worse DFS than T4 abc breast cancer but not significant (p = 0.505). The survival of patients with T1N3 and T2N3 tumors was higher than the other groups, and patients with T4N3 tumors showed the worst survival outcomes in terms of DFS, CSS. Using new suggested classification, in cohort III, the stage IIIB HR for CSS was changed from 15.4 (95% CI 10.6-22.1) in the AJCC 6th edition to 12.6 (95% CI 10.1-15.6) in the proposed new staging system. The stage IIIC HR for CSS was changed from 13.3 (95% CI 10.7-16.4) in the AJCC 6th edition to 18.9 (95% CI 14.0-25.6) in the proposed new staging using stage I as a reference. Reclassification of T4 any N disease as stage IIIC and T1-3N3 disease as stage IIIB is appropriate.

Recurrent bilateral breast abscess due to nontuberculous mycobacterial infection

Since recurrent bilateral breast infection due to nontuberculous mycobacterium (NTM) is rare, its diagnosis is easily overlooked; in addition, complete recovery is often difficult to achieve. We report a case of recurrent bilateral infection in a 35-year-old woman who had completed treatment for NTM. Although various infectious diseases show similar clinical conditions and imaging findings, recurrences should raise suspicion of NTM infection, and this possibility should be considered in differential diagnoses.

Dietary intake and breast cancer among carriers and noncarriers of BRCA mutations in the Korean Hereditary Breast Cancer Study

BACKGROUND

Soy intake is associated with a lower risk of breast cancer. However, it is unclear whether the same reduction in risk associated with high soy intake is also applicable to familial or genetic breast cancer.

OBJECTIVE

The aim of this study was to assess the dietary factors among carriers and noncarriers of BRCA mutations in the Korean Hereditary Breast Cancer Study (KOHBRA).

DESIGN

The KOHBRA Study is an ongoing project composed of affected breast cancer patients and familial members of breast cancer cases with BRCA mutations. To assess the association between dietary diversity and breast cancer risk, an HR was estimated by comparing affected subjects with their familial nonaffected members. To assess the interaction between the combination of BRCA mutation and diet diversity, the case-only OR (COR) was estimated by comparing BRCA mutation carriers and noncarriers only in affected subjects.

RESULTS

Soy product intake was associated with a lower risk of breast cancer in carriers (HR: 0.39; 95% CI: 0.19, 0.79 for the highest quartile). The highest quartile of meat intake was associated with a higher risk of breast cancer regardless of BRCA mutation in carriers (HR: 1.97; 95% CI: 1.13, 3.44) and noncarriers (95% CI: 1.41; 1.12, 1.78). The associations of meat intake and soybean intake for breast cancer were more prominent in BRCA2 mutation carriers. In the analysis with only cases, the highest quartile of soy intake, but not meat intake, was associated with BRCA-related breast cancer (COR: 0.57; 95% CI: 0.36, 0.91).

CONCLUSION

Our study suggests that soy product consumption is associated with lower breast cancer risk and it had an interaction with BRCA mutation.

Weight Gain and its Correlates among Breast Cancer Survivors

PURPOSE

Weight gain after diagnosis of breast cancer is a profound issue that may negatively impact cancer prognosis. However, most existing research on weight change has been conducted in Western countries. In addition, several factors related to weight gain have been reported; however, the evidence is inconsistent. The purpose of this study was to examine weight gain and its correlates among Korean breast cancer survivors.

METHODS

A total of 132 female breast cancer survivors were recruited from one university hospital in South Korea. Participants completed anthropometric measurements (i.e., body weight, height) and a self-reported questionnaire, including the International Physical Activity Questionnaire Short Form and Mini Dietary Assessment.

RESULTS

The mean weight change was -0.09 kg (SD = 4.28). Only 27 women (19.7%) gained more than 5% of their weight at diagnosis, 59.1% maintained weight, and 21.2% lost weight. In multivariate logistic regression analysis, significant correlates of weight gain were younger age, obesity at diagnosis, duration of more than 36 months since diagnosis, and low diet quality.

CONCLUSION

Younger women, women who were obese at diagnosis, women with more than 36 months since diagnosis, or women who showed lower diet quality should be considered at high-risk for weight gain. Findings from our study suggest that optimal weight management strategies should be developed using ethnically- or culturally-appropriate approaches.