Recommendations for standardized pathological characterization of residual disease for neoadjuvant clinical trials of breast cancer by the BIG-NABCG collaboration

Neoadjuvant systemic therapy (NAST) provides the unique opportunity to assess response to treatment after months rather than years of follow-up. However, significant variability exists in methods of pathologic assessment of response to NAST, and thus its interpretation for subsequent clinical decisions. Our international multidisciplinary working group was convened by the Breast International Group-North American Breast Cancer Group (BIG-NABCG) collaboration and tasked to recommend practical methods for standardized evaluation of the post-NAST surgical breast cancer specimen for clinical trials that promote accurate and reliable designation of pathologic complete response (pCR) and meaningful characterization of residual disease. Recommendations include multidisciplinary communication; clinical marking of the tumor site (clips); and radiologic, photographic, or pictorial imaging of the sliced specimen, to map the tissue sections and reconcile macroscopic and microscopic findings. The information required to define pCR (ypT0/is ypN0 or ypT0 yp N0), residual ypT and ypN stage using the current AJCC/UICC system, and the Residual Cancer Burden system were recommended for quantification of residual disease in clinical trials.

Retrospective Comparison of Chemotherapy-Induced Myelotoxicity in Patients with Ovarian Cancer Under and Over 60 Years of Age

We examined whether women aged 60 years or older with ovarian cancer who were treated with surgery and postoperative chemotherapy are at higher risk of developing grade 4 hematological toxicity. Seventy-five patients were included: 34 patients aged < 60 years (group I) were compared with 41 patients aged > or =60 years (group II) after postoperative treatment with single-agent carboplatin or carboplatin/taxane combination chemotherapy. Secondary prophylaxis with granulocyte colony-stimulating factors was performed to avoid dose reduction and chemotherapy delay. A total of 450 chemotherapy cycles was completed. Anemia and thrombocytopenia were mild in both groups. Overall, grade 4 neutropenia developed in 41% (group I) and in 49% (group II) (p=0.51). Febrile neutropenia occurred in 12% and 2%, respectively (p=0.17). The carboplatin/taxane combination was associated with grade 4 neutropenia in 42% (group I) and 58% (group II) (p=0.21). Women > or =60 years are not at higher risk of developing severe myelotoxicity than their younger counterparts, particularly after treatment with carboplatin/taxane combination chemotherapy.

Non-Sentinel Lymph Node Status of Patients with T1/T2 Breast Cancer and Micrometastasis in the Sentinel Lymph Node

Background: Micrometastatic disease in the sentinel lymph node is still an indication for complete axillary lymph node dissection. To further reduce morbidity in breast cancer patients the omission of complete axillary lymph node dissection in patients with micrometastasis in the sentinel lymph node would be desirable.Methods: We retrieved our data-base and looked for the non-sentinel lymph node status in patients with micrometastasis in the sentinel lymph node.Patients with primary T1/T2 breast cancer and sentinel lymph node biopsy were examined for their sentinel lymph node status. Patients with a micrometastasis in the sentinel lymph node, who received a complete axillary lymph node dissection were eligible for evaluation. Patients with a micrometastisis in the sentinel lymph node, who did not receive complete axillary lymph node dissection and patients after primary systemic therapy were excluded.Results: 103 patients were eligible for evaluation. All patients had micrometastases (0,2 to 2,0mm) in the sentinel lymph nodes. In total 15/103 patients (14.6%) had a further metastasis in one or two non-sentinel lymph nodes. 8/103 patients (7.8%) had one macrometastasis in a non-sentinel lymph node with sizes from 2.1mm to 5.0mm. 3/103 patients (2.9%) had a micrometastasis in two non-sentinel lymph nodes and 4/103 patients (3.9%) had one micrometastasis in one non-sentinel lymph node.Mean age of the patients was 57 years, 34 (33%) being premenopausal and 69 (67%) being postmenopausal. 22 patients (21.4%) received immediate axillary dissection after sentinel lymph node biopsy, but 81 patients (78.6%) had a secondary axillary lymph node dissection after the final pathological report. In 19 patients (18.4%) the micrometastasis in the sentinel lymph node could be detected by frozen sections, in 77 patients (74.8%) by serial sections at 250µm in the paraffin embedded sentinel lymph node and in 22 patients (21.4%) by immunohistochemistry only.Discussion: As long as we are lacking reliable methods for predicting the non-sentinel lymph node status for patients with micrometastases in the sentinel lymph node, and as long as the impact of micrometastases in the axilla are subject of debate, axillary lymph node dissection should be performed after sentinel lymph node biopsy with micrometastases in the sentinel lymph node.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1034.

Ipsilateral breast tumor recurrence rates in breast cancer patients treated with preoperative chemotherapy, breast conserving surgery and intraoperative radiotherapy with electrons

Abstract #5156

Introduction: Ipsilateral breast tumor recurrence (IBTR) rates are reported to be increased in patients treated with breast conserving surgery after preoperative chemotherapy. Aim of this study was to evaluate the IBTR rate in patients who were treated with preoperative chemotherapy followed by breast conserving surgery and intraoperative radiotherapy with electrons (IOERT).&#x2028; Patients and Methods: 84 patients with clinical stage II or III breast cancer were included in the study. Patients received 3 to 6 cycles of anthracyclin/taxane containing preoperative chemotherapy. All patients had breast conserving surgery with sentinel node biopsy and axillary lymph node dissection and received intraoperative radiotherapy with 9 Gy to the 90% reference isodose as an anticipated boost radiation. Whole breast radiotherapy (WBRT) was performed after surgery for all patients.&#x2028; Results: Pathologic complete response was achieved in 18/84 (21%) patients. Mean resection volume was 250 ml. After a median follow-up of 30.5 months (range 6 – 77 months) no IBTR could be observed. One patient developed a locoregional recurrence in the axilla and nine patients developed distant disease, five of those died of disease. Three patients developed contralateral breast cancer. 71 patients are alive without evidence of disease.&#x2028; Conclusion: Breast conserving surgery with IOERT in boost modality after preoperative chemotherapy is a reliable tool for the prevention of IBTR. The period between IOERT and WBRT is short as no adjuvant chemotherapy is necessary. Cosmetic outcome is excellent.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5156.

Hormone receptor status and pathologic response of HER2-positive breast cancer treated with neoadjuvant chemotherapy and trastuzumab

BACKGROUND

The aim of this study was to compare the extent of pathologic response in patients with HER2-positive (HER2+) breast cancer treated with standard neoadjuvant chemotherapy, with or without trastuzumab (H), according to hormone receptor (HR) status.

PATIENTS AND METHODS

We included 199 patients with HER2+ breast cancer from three successive cohorts of neo-adjuvant chemotherapy on the basis of paclitaxel (Taxol) (P) administered weekly (w) or three weekly (3-w), followed by 5-fluorouracil (F), doxorubicin (A) or epirubicin (E), and cyclophosphamide (C). Residual cancer burden (RCB) was determined from pathologic review of the primary tumor and lymph nodes and was classified as pathologic complete response (pCR) or minimal (RCB-I), moderate (RCB-II), or extensive (RCB-III) residual disease.

RESULTS

In HR-positive (HR+) cancers, a higher rate of pathologic response (pCR/RCB-I) was observed with concurrent H + 3-wP/FEC (73%) than with 3-wP/FEC (34%, P = 0.002) or wP/FAC (47%; P = 0.02) chemotherapy alone. In HR-negative (HR-) cancers, there were no significant differences in the rate of pathologic response (pCR/RCB-I) from 3-wP/FAC (50%), wP/FAC (68%), or concurrent H + 3-wP/FEC (72%).

CONCLUSIONS

Patients with HR+/HER2+ breast cancer obtained significant benefit from addition of trastuzumab to P/FEC chemotherapy; pathologic response rate was similar to that seen in HR-/HER2+ breast cancers.

Residual specimen cellularity after neoadjuvant chemotherapy for breast cancer

BACKGROUND

Neoadjuvant chemotherapy for breast cancer reduces tumour cellularity, the percentage of the primary tumour area that is composed of invasive tumour cells. Minimal residual tumour cellularity (5 per cent or less of tumour area composed of invasive tumour cells) may be associated with an increased risk of false-negative intraoperative margins. The aim of this study was to evaluate the incidence of minimal residual tumour cellularity after neoadjuvant chemotherapy and its impact on the frequency of false-negative margins and conversion from breast-conserving surgery to mastectomy.

METHODS

The final pathology slides of 510 patients who had surgery after neoadjuvant chemotherapy were reviewed.

RESULTS

Of 396 patients with residual invasive breast cancer after neoadjuvant chemotherapy, 100 specimens (25.3 per cent) had minimal residual cellularity; this was more frequent in patients with invasive lobular carcinoma (17.0 versus 5.1 per cent; P < 0.001) or well and moderately differentiated carcinoma (68.0 versus 52.4 per cent; P = 0.007). Among 149 patients who had initial breast-conserving surgery, false-negative intraoperative margin rates were 23 per cent in specimens with minimal and 13.8 per cent in those with higher residual cellularity (P = 0.210). There was no significant difference in the rate of conversion to mastectomy between the groups.

CONCLUSION

Minimal residual cellularity after neoadjuvant chemotherapy occurred in about 25 per cent of specimens, but did not alter the rate of false-negative intraoperative margins.

The impact of hormone receptor status on pathologic response of HER2-positive breast cancer treated with neoadjuvant chemotherapy with or without trastuzumab

533

Background: The aim of this study was to compare the extent of pathologic response in HER2-positive patients treated with standard neoadjuvant chemotherapy with or without trastuzumab according to hormone receptor (HR) status. Methods: The study included 199 patients with HER2-positive disease treated in clinical trials of neoadjuvant chemotherapy. Eighty-nine patients treated with 3- weekly paclitaxel and concurrent trastuzumab followed by 5-fluorouracil, epirubicin, and cyclophosphamide (FEC) were compared with 110 patients treated with weekly or 3-weekly paclitaxel followed by FEC or FAC. Residual cancer burden (RCB), a measurement of residual disease (RD) from pathologic review of the primary tumor and lymph nodes, was classified as pathologic complete response (pCR), RCB-I (near-pCR, minimal RD), RCB-II (moderate RD), or RCB-III (extensive RD). RCB was compared between treatment groups according to HR status. Results: In HR-negative patients, similar pCR rates were achieved with weekly T/FAC as with 3-weekly T/FEC and trastuzumab (61% and 65%, respectively). However, in HR-positive patients, higher pCR rates were achieved with 3-weekly T/FEC and trastuzumab (47%) than with the weekly T/FAC (25%; p=0.04) or 3-weekly T/FAC (19%; p=0.01) ( Table 1 ). Near pCR (RCB-I) was slightly higher in HR-positive (26%) than in HR-negative patients treated with 3-weekly T/FEC and trastuzumab (11%; p=0.07). Conclusions: Patients with HR- negative/HER2-positive breast cancer had similar pathologic response rates from addition of trastuzumab to 3-weekly T/FEC or from weekly T/FAC chemotherapy. Patients with HR-positive/HER2-positive breast cancer obtained significant benefit from addition of trastuzumab to 3- weekly T/FEC, compared to 3-weekly T/FAC or weekly T/FAC. The combination of weekly T/FEC with trastuzumab as neoadjuvant chemotherapy should be evaluated.

[Table: see text]

[Table: see text]

Effect on patient outcome of residual DCIS in patients with complete eradication of invasive breast cancer after neoadjuvant chemotherapy

530

Background: To determine whether residual ductal carcinoma in situ (DCIS) after completion of preoperative chemotherapy affects the outcome of patients with hiostologically defined complete eradication of invasive cancer. Methods: Retrospective analysis of a database including 2,302 breast cancer patients treated prospectively with neoadjuvant chemotherapy at the UT MD Anderson Cancer Center between 1980 and 2004 was performed. The overall, disease-free and local recurrence-free survivals were compared for patients with no residual invasive or in situ cancer (pCR) and those with no residual invasive cancer but persistent in situ disease (pCR+DCIS). Results: The mean follow-up was 250 months. Of the 2,302 treated patients 78 (3.4%) had pCR, 199 (8.6%) had pCR+DCIS, and 2025 (88%) had residual invasive cancer. The 5-year (87.1% in both) and 10-year (81.3% vs 81.7%) disease-free survival rates were similar for cases with pCR and pCR+DCIS. The 5-year (91.9% vs. 92.5%) and 10-year (91.8% vs. 92.5%) overall survival rates were also similar and significantly better than the rate of patients with residual invasive cancer (74.4%, p<0.001). The 5-year local-regional recurrence-free survival rates were also not different for patients with pCR (92.8%, 95% CI: 86.1%-96.4%) and those with pCR+DCIS (90.9%, 95% CI: 77.3%- 96.5%), p=0.63. Conclusions: Residual DCIS in patients who experience complete eradication of the invasive cancer in the breast and lymph nodes does not adversely affect survival or local recurrence rate. Inclusion of cases with residual DCIS in the definition of pathologic complete response is justified when this outcome is used as early surrogate for long term-survival.

No significant financial relationships to disclose.

A new measurement of residual cancer burden to predict survival after neoadjuvant chemotherapy

536

Background: The strength of association between tumor response and survival is critical for neoadjuvant chemotherapy trials. Pathologic complete response (pCR) reliably predicts survival benefit, but residual disease contains a range of pathologic responses that likely contain different prognostic groups, including near complete response and resistance. Methods: Pathologic slides and reports were reviewed from 432 patients in two completed neoadjuvant trials: 1) fluorouracil, doxorubicin and cyclophosphamide (FAC) in 189 patients, and 2) paclitaxel followed by FAC (T/FAC) in 243 patients. Paclitaxel was administered as twelve weekly (n=126) or four 3-weekly cycles (n=117). Residual cancer burden (RCB) was calculated as an index that combines pathologic measurements of primary tumor (size and cellularity) and nodal metastases (number and size). We compared four RCB categories, from RCB-0 (pCR) to RCB-3 (chemoresistant), and post-treatment revised AJCC Stage (0-III) for prediction of distant relapse-free survival (DRFS) in multivariate Cox regression analyses (stratified by ER status). Results: The pCR rate was greater after T/FAC than FAC (24% vs. 16%, LR p<0.05), and after weekly (vs. 3-weekly) paclitaxel in T/FAC (30% vs. 16%, LR p<0.01). In patients with residual disease, RCB measurements were significantly lower after T/FAC than FAC (t-test, p<0.0001), but were not different between paclitaxel schedules in T/FAC. RCB was a continuous predictor of DRFS after T/FAC (HR=1.86, 95%CI 1.51–2.30) or FAC (HR=1.67, CI 1.38–2.01) with median follow-up 5 and 8 years, respectively. The resistant category RCB-3 predicted relapse more strongly than AJCC Stage III and identified a larger group of high-risk patients ( Table ). Conclusions: RCB is a new continuous measure of pathologic response that is defined from routine pathologic materials, represents the distribution of residual disease, is a significant predictor of DRFS, and defines chemotherapy resistance more effectively than revised AJCC Stage.

[Table: see text]

[Table: see text]

200 Sentinel lymph node biopsies without axillary lymph node dissection -- no axillary recurrences after a 3-year follow-up

The aim of this study is to evaluate the rate of axillary recurrences in sentinel lymph node (SLN)-negative breast cancer patients after sentinel lymph node biopsy (SLNB) alone without further axillary lymph node dissection (ALND). Between May 1999 and February 2002, 333 consecutive patients with primary invasive breast cancer up to 4 cm and clinically negative axillae were entered into this prospective study. Sentinel lymph nodes were identified using the combined method with blue dye (Patent blue V®) and technetium 99m-labelled albumin (Nanocoll®). Sentinel lymph nodes were examined by frozen sections, standard haematoxylin and eosin staining and immunohistochemistry staining. In SLN-positive patients, ALND was performed. Sentinel lymph node-negative patients had no further ALND. The SLN identification rate was 98.5% (328 out of 333). In all, 128 out of 328 (39.0%) patients had positive SLNs and complete ALND. A total of 200 out of 328 (61.0%) patients were SLN negative and had no further ALND. The mean tumour size of SLN-negative patients was 16.5 mm. The mean number of SLNs removed was 2.1 per patient. There were no local or axillary recurrences at a median follow-up of 36 months. The absence of axillary recurrences after SLNB without ALND in SLN-negative breast cancer patients supports the hypothesis that SLNB is accurate and safe while providing less surgical morbidity than ALND. Short-term results are very promising that SLNB without ALND in SLN-negative patients is an excellent procedure for axillary staging in a cohort of breast cancer patients with small tumours.

Comparison of quality of life and arm complaints after axillary lymph node dissection vs sentinel lymph node biopsy in breast cancer patients

The sentinel lymph node biopsy (SLNB) represents a minimal invasive surgical method for axillary staging in patients with primary breast cancer. In a prospective study, evaluation of quality of life (QOL) and arm morbidity was performed before surgery on a total of 56 breast cancer patients. The EORTC QLQ-C30 and EORTC QLQ-BR23 questionnaires were used for QOL assessment. Assessment of pain was additionally observed using the McGill Pain Questionnaire. Arm mobility was observed by goniometric measurement of arm movement. Data were collected before surgery (t1), 1 week after discharge (t2) and 9-12 months after surgery (t3). The type of axillary surgery does not seem to affect global QOL at a short-time follow-up, but patients recover sooner after SLNB. Body image and sexual functioning remain stable in both types of axillary surgery. Arm/shoulder pain was reported in 36% of patients after SLNB in comparison to 68% receiving axillary lymph node dissection (ALND), and 'numbness' was reported only in 4% of patients in the SLNB group vs 19.3% after ALND. Abduction, flexion and horizontal adduction of the affected arm show significant impairment after ALND. Breast cancer patients should be counselled about the benefits of SLNB over ALND concerning QOL and postsurgery side effects in a short-term follow-up.

[Sentinel lymph node biopsy in breast cancer patients--results and experience after 500 sentinel lymph node biopsies]

INTRODUCTION

Sentinel lymph node biopsy (SLNB) is a widely used technique for axillary staging in breast cancer patients. The principle to evaluate the axillary status of a breast cancer patient with a less invasive surgery than axillary lymph node dissection (ALND) meets the new minimally invasive concept in breast cancer surgery. Some breast cancer centers proceed to SLNB without ALND in SLN-negative patients.

PATIENTS AND METHODS

Between March 1998 and March 2002, 500 SLNBs were performed. After a learning period with SLNB and ALND in 75 patients with a sensitivity of 96.2% and a false-negative rate of 3.8%, SLNB alone without further ALND was performed in a group of patients. In addition, the feasibility of SLNBin patients with locally advanced breast cancer, in patients after neoadjuvant chemotherapy and in patients with multicentricity was evaluated. The combined method with blue dye and technetium-99m-labeled human albumin for identification of SLNs was applied.

RESULTS

500 SLNBs were performed. The identification rate was 86.2%. After exclusion of patients with neoadjuvant chemotherapy and patients with multicentricity, the identification rate was 94.5%. SLNs were positive in 41.3% of patients and negative in 58.7% of patients.

DISCUSSION

SLNB is an excellent method for axillary stag-ing and an alternative for ALND in a certain group of breast cancer patients.

Sentinel lymph node biopsy alone without axillary lymph node dissection--follow up of sentinel lymph node negative breast cancer patients

AIMS

To evaluate the rate of axillary recurrences in sentinel lymph node (SLN) negative breast cancer patients after sentinel lymph node biopsy (SLNB) alone without further axillary lymph node dissection (ALND).

METHODS

Between May 1999 and February 2001 all patients who had primary invasive breast cancer and were SLN negative were eligible for this prospective study. SLNB was performed by using the combined method with radioactive tracer and blue dye. SLNs were examined by frozen section, standard H/E staining and immunohistochemistry staining. SLN negative patients did not receive further ALND. Follow-up was done three-monthly with clinical controls, blood samples and ultrasound of the breast and axilla. An annual mammogram was performed.

RESULTS

116 patients with T1 or T2 invasive breast cancer were included in this trial. All 116 patients had negative SLNs in frozen sections, in H/E staining and in immunohistochemistry staining. The mean number of removed SLNs was 2.03+/-1.22. Mean tumor size was 17.15+/-7.62 mm. Postmenopausal patients totalled 79.3 and 20.7% of patients were premenopausal. No local or axillary recurrences occurred at a mean duration of follow-up of 22.12+/-6.38 months.

CONCLUSION

The absence of axillary recurrences after SLNB without ALND in SLN negative breast cancer patients supports the hypothesis that SLNB is accurate and safe while providing less surgical morbidity. Short term results are very promising. SLNB without ALND in SLN negative patients is an excellent procedure for axillary staging in a cohort of breast cancer patients with small tumors.

Intraoperative radiotherapy given as a boost after breast-conserving surgery in breast cancer patients

Conventional radiotherapy after breast-conserving therapy is confined to 50-55 Gy external beam radiation therapy (EBRT) to the whole breast and 10-16 Gy external boost radiation to the tumour bed or brachytherapy to the tumour bed. Local recurrence rate after breast-conserving surgery varies between 5 and 18%. External boost radiation can partially miss the tumour bed and therefore can result in local failure. Intra-operative radiotherapy (IORT) as a high precision boost can prevent a 'geographical miss'. From October 1998 to December 2000, 156 patients with stage I and stage II breast cancer were operated upon in a dedicated IORT facility. After local excision of the tumour, the tumour bed was temporarily approximated by sutures to bring the tissue in the radiation planning target volume. A single dose of 9 Gy was applied to the 90% reference isodose with energies ranging from 4 to 15 MeV, using round applicator tubes 4-8 cm in diameter. After wound healing, the patients received additional 51-56 Gy EBRT to the whole breast. No acute complications associated with IORT were observed. In 5 patients, a secondary mastectomy had to be performed because of tumour multicentricity in the final pathological report or excessive intraductal component. 2 patients developed rib necroses. In 7 patients, wound healing problems occurred. After a mean follow-up of 18 months, no local recurrences were observed. Cosmesis of the breast was very good and comparable to patients without IORT. Preliminary data suggest that IORT given as a boost after breast-conserving surgery could be a reliable alternative to conventional postoperative fractionated boost radiation by accurate dose delivery and avoiding geographical misses, by enabling smaller treatment volumes and complete skin-sparing and by reducing postoperative radiation time by 7-14 days.

Prospective assessment of quality of life of female cancer patients

OBJECTIVE

The aims of this study were to compare the quality of life (QOL) of women with different cancer sites; to identify predictors of QOL; and to examine the agreement between patient self-reported QOL and QOL ratings provided by clinicians and significant others.

METHODS

A prospective study was conducted including 248 patients with gynecologic and breast cancer. QOL data were collected at six time points before, during, and after treatment, using the EORTC QLQ-C30 and the Spitzer QL index (QL-I).

RESULTS

Baseline assessments showed comparable QOL scores among patients with different gynecologic malignancies and breast cancer. During active treatment breast cancer patients had significantly higher mean scores in physical functioning compared to women with gynecologic cancers and higher scores in role functioning compared to patients with cervical cancer. After completion of treatment there were no statistically significant differences in QOL among the groups. For all women, global QOL and emotional functioning were mostly affected during and after treatment. Regression analysis showed that patients' global QOL was significantly predicted by severity of surgery (t = 3.903, P < 0.01) and pretreatment performance status (t = 3.116, P = <0.01). Comorbidity, family support, number of treatments, age, and stage of disease were not predictive. The comparison of patient self-rated QOL and observer-rated QOL showed that the QL-I mean scores of health providers and relatives were generally in close agreement with those of patients. Intraclass correlations were moderate to high during active treatment and excellent after completion of treatment.

CONCLUSION

In female cancer patients, global QOL and emotional functioning are mostly affected during the course of disease, independent of their diagnosis. Significant others and health professionals are able to provide useful information on QOL of patients recovering from cancer.