P4-09-28: Comparison of Oncotype DX (ODX) and Mammostrat (MS) Risk Estimations and Correlations with Histologic Tumor Features in Low Grade, ER-Positive Invasive Breast Carcinoma (BC)

Several molecular tests have been developed to estimate risk of distant recurrence (RDR) and help clinical decision-making regarding adjuvant chemotherapy in early stage BC. The ODX assay is a 21-gene expression profile mainly based on expression levels of genes related to hormone receptor / HER2 signaling and cell proliferation. MS is an immunohistochemistry-based assay measuring the expression of five markers thought to play a significant role in BC biology. Although both validated tests were shown to stratify patients into groups with low, intermediate and high RDR, the tests have not been compared head-to-head in the same cohort of patients and little data is available regarding their correlation with clinicopathologic tumor features. We have previously shown that a proliferative, cellular stroma and inflammatory cells associated with tumor cells may account for unexpected intermediate/high risk estimations based on ODX in low grade BC. In this study we compared the clinicopathologic tumor features with risk estimations by ODX and MS in 106 low grade ER-positive BC. The histologic features of tumors were prospectively determined without knowledge of test results. The tumor stroma was evaluated for increased cellularity and presence of inflammatory cells. Double immunostain for pancytokeratin and Ki67 was performed to assess cell proliferation in cancer vs stromal/inflammatory cells. Based on ODX and MS, among the 106 cases 68, 38 and 0, and 91, 14 and 1 tumors showed low, intermediate and high RDR, respectively. Assessment of the concurrence between the tests to predict low vs intermediate/high RDR showed a kappa value of 0.0541. There was no statistically significant correlation between ODX Recurrence Score (RS) and MS risk index values. We found no correlation between low vs intermediate/high risk estimation by either test and patient age, tumor size, nuclear atypia, mitotic rate, ER and HER2 expression levels. BC with intermediate/high RDR by ODX, but not by MS, showed significantly lower PR expression, increased stromal cellularity and presence of inflammatory cells. Double immunostains showed increased proliferation in stromal/inflammatory cells compared to cancer cells in cases showing intermediate/high RDR by ODX; no such association was seen with regards to MS risk estimations. The ratio of Ki67-positive stromal/inflammatory vs tumor cells >1 had an area under the curve of 0.8929 (p<0.0001) and 0.5026 (p=0.9823) to predict intermediate/high RDR based on ODX and MS, respectively. Cases showing intermediate/high RDR by ODX but low risk by MS were associated with increased stromal cellularity, presence of inflammatory cells and increased numbers of Ki-67 positive stromal/inflammatory cells, compared to cases showing low risk by both assays. Our results suggest that low grade ER-positive BC with increased stromal/inflammatory cell proliferation may show an apparent increased RDR as assessed by ODX, which uses RNA extracted from a mixture of tumor and stromal/inflammatory cells in the assay. MS, which examines cancer cells only (thus, not influenced by stromal and inflammatory cells), may provide a better estimation of likely tumor behavior in low grade BC.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-09-28.

Results of Oncotype DX in early-stage invasive lobular carcinoma

59

Background: The Oncotype DX (ODX) genomic assay has been used since 2004 to estimate prognosis and guide adjuvant treatment in patients with estrogen receptor-positive, node-negative invasive breast tumors. However, the impact of ODX assay testing in patients with invasive lobular carcinoma (ILC) has not been specifically reported. We describe our experience in patients with ILC who underwent ODX assay testing and how this affected adjuvant treatment.

Methods: An IRB approved retrospective review was performed on all patients undergoing treatment for early stage, node-negative ILC from 2006-2011. All cases were reviewed by a single pathologist (GA) for verification of histology and subtype. The impact of ODX assay testing on treatment management was evaluated.

Results: Thirty-nine patients underwent ODX genomic assay testing of early stage, node-negative ILC with a median age of 62 years. ILC tumor classification included classic (67%), pleomorphic (23%) and mixed (10%) subtypes with a median tumor size of 2.0 cm (0.6-6.0). Ninety-seven percent of tumors were estrogen receptor-positive, 74% progesterone receptor-positive. Median ODX recurrence score was 15 (0-34) with an ODX 10-yr risk of 10% (3-23). ODX risk classification was: Low (N=26), Intermediate (N=12), and High (N=1). There was no difference in ODX recurrence score or risk classification between ILC subtypes (p=0.52 and p=0.35, respectively). Adjuvant chemotherapy was used in 26% (TC N=8, AC N=1, FEC 100 N=1). Tumor size or ILC tumor subtype were not significant for adjuvant chemotherapy use while tumor grade (p=0.046), ODX recurrence score (22.8 vs 13.6, p<0.0001), ODX risk classification (p=0.009) and ODX 10 year risk (15.9 vs 9.0, p<0.0001) were significant. With a median follow up of 16.5 months, there were no recurrences or tumor-related deaths.

Conclusions: ODX testing on early stage node-negative ILC may serve as a useful adjunct when counseling patients on the decision for adjuvant therapy. The long-term impact on recurrence or survival in patients with ILC who receive adjuvant chemotherapy based on ODX recurrence score remains undetermined and warrants further testing.

Abstract P6-01-03: Invasive Micropapillary Carcinoma (IMPC) of the Breast: An Uncommon but Aggressive Special Type of Breast Cancer

IMPC is an uncommon type of invasive breast cancer. However, in comparison to invasive ductal carcinoma of no special type (IDC), it is reported to have a more aggressive behavior. Our objective was to compare and contrast IMPC with IDC in terms of clinicopathologic features and outcome. One hundred-thirty-one IMPC cases were compared to 1295 IDC and 189 invasive lobular carcinoma (ILC). Medical records and pathology slides were reviewed for traditional factors (tumor grade, lymphatic invasion [LVI], lymph node [LN] status, stage, receptor status, treatment) and specific tumor features (extent of retraction artifact [RA]). Clinicopathologic features between groups were compared and clinical outcome of IMPC was recorded. All patients were women with a median age of 57.6 yrs (range 22-93) for IMPC, 56.3 yrs (range 22-96) for IDC and 60.7 (range35-85) for ILC, respectively (P&lt;0.0001). There were no differences noted for family history, race, or presentation (symptomatic vs. screening). Surgical treatment was partial mastectomy in 770 (47.7%) and mastectomy in 845 (52.3%). All patients had axillary lymph node biopsy. The median tumor size was 2.2 (range 0.3-15.2) cm for IMPC, 2.0 (range 0.05-11.0) cm for ILC and 1.7 (range 0.05-19.0) cm for IDC, respectively (P&lt;0.). The extent of micropapillary features in IMPC ranged from 3% to 100% with a median value of 20%. LVI was more likely to be present in IMPC (67.9%) compared to IDC (28.3%) and ILC (6.9%) (P&lt;0.0001). Axillary LN metastases were seen in 71.8% of IMPC compared to 44.1 % of IDC and 54.5% of ILC (P&lt;0.0001). IMPC and ILC was significantly more frequently ER and PR positive (P&lt;0.0001 each) compared to IDC, while ILC was significantly less frequently HER2 positive (2.8%) compared to IDC (17.9%) and IMPC (8.2%). The mean percent of tumors showing retraction artifact (RA) was 60.2% in IMPC compared to 25.4% in IDC and 3.8% in ILC (P&lt;0.0001). During a median follow-up of 24.3 months 19 (14.5%) and 17 (13.0%) IMPC patients developed local and distant recurrence, respectively. IMPC is an uncommon special type of invasive breast cancer but it is more aggressive in reference to IDC and ILC based on larger tumor size and more frequent the presence of LVI and LN metastases. The presence of IMPC features in breast cancers, even if present focally, should alert the clinician for the high likelihood of lymphatic tumor spread and an adverse biologic behavior.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-01-03.

Estimation of Risk of Recurrence of Early Stage Estrogen Receptor Positive Breast Carcinoma by Surgical and Medical Oncologists and Pathologists Compared to the Oncotype Dx® Recurrence Score

Background: The decision to use adjuvant chemotherapy in patients with early stage breast cancer is based in part on the estimation of risk of tumor recurrence by physicians, which traditionally relies heavily on tumor size, nodal status and a set of biologic tumor characteristics such as hormone receptor and HER2 expression. The Oncotype DX® assay is a 21-gene expression profile aiming to improve risk stratification, recurrence prediction and optimize selection of patients for adjuvant chemotherapy.Methods: We selected 154 consecutive patients with early stage estrogen receptor (ER) positive breast cancer and available Oncotype Dx® recurrence score (RS) for the study. Clinicopathologic data, including patient age, menopausal status, tumor size, histologic type, grade, mitotic activity, presence of lymphatic invasion (LVI), nodal status, hormone receptor and HER2 status on all patients were provided to four surgical oncologists, four medical oncologists and three pathologists, specializing in breast cancer diagnosis and management. Participants were asked to estimate the risk of recurrence of tumors based on available clinicopathologic data and to provide the three most important tumor features their risk estimates were based on. Risk estimates of participants were compared with RS results.Results: Based on the Oncotype Dx® results, 95 (61.7%), 45 (29.2%) and 14 (9.1%) tumors were of low (RS &lt;18), intermediate (RS 18-30) and high (RS ≥31) risk, respectively. RS values showed a highly significant correlation with tumor grade, mitotic activity, LVI, hormone receptor and HER2 status, while no correlation with patient age, menopausal status, tumor size and histologic type was found. Participants' risk estimates agreed with those of the Oncotype Dx® assay in 54.2 ± 2.3 % (mean ± SEM, range 41.6 - 63.0%) of cases, while the risk of recurrence was over- and underestimated compared to RS results in 31.8 ± 3.1% (16.2 - 43.5%) and 14.1 ± 1.4% (7.1 - 22.7%), respectively. The rates of overestimation were significantly higher than those of underestimation (p = 0.0003). Although medical oncologists tended to overestimate the risk more frequently (38.1 ± 2.0%) compared to surgeons (28.7 ± 5.9%) and pathologists (27.5 ± 7.8%), the difference did not reach statistical significance. Estimation of the agreement of participants' risk assessment with RS results showed a mean kappa value of 0.2955 (range 0.1506 - 0.4123). No statistically significant difference in overall concurrence with RS results was found between surgeons, medical oncologists and pathologists. Participants ranked tumor stage/nodal status, hormone receptor status and tumor size to be the most important features when estimating recurrence risk.Conclusions: Based on traditional clinicopathologic features alone, surgeons, medical oncologists and pathologists tend to overestimate the risk of tumor recurrence as compared to Oncotype Dx® assay results. The RS may provide additional information regarding the intrinsic biological features of ER positive breast cancers and help tailoring treatment recommendations.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4061.

Margin Assessment in Breast Conservation for Ductal Carcinoma In Situ

IntroductionBreast conserving surgery in the setting of ductal carcinoma in situ (DCIS) produces many challenges. Re-excision rates for close or negative margins after lumpectomy are common due to difficulty in intraoperative margin status assessment. The objective of this study was to review our experience with various margin assessment techniques in the setting of a preoperative diagnosis of DCIS on core needle biopsy (CNB).MethodsA prospectively gathered database of surgically-treated breast cancer patients was reviewed for patients with a diagnosis of DCIS as the most significant lesion on CNB from 1997 to 2009. Of 425 patients with a diagnosis of DCIS by CNB, 231 patients underwent a lumpectomy. Patients' age, tumor characteristics, type of surgery, margin assessment technique, and follow up data were recorded.Results231 patients underwent a lumpectomy following a CNB of DCIS. 138 patients (59.7%) had intra-operative touch prep (TP) analysis of all 6 margins, 39 patients (16.9%) underwent intra-operative gross evaluation of margins, 53 (22.9%) patients had no intra-operative analysis, and one patient (0.4%) had a frozen section analysis. Success at achieving negative margins (&gt;2mm) with initial lumpectomy was 66.7% (92/138) for TP analysis, 56.4% (22/39) for gross evaluation, and 52.8% (28/53) for no margin assessment. These percentages did not reach statistical significance by odds ratios (TP to Gross p= 0.24, TP to None p=0.08, Gross to None p=0.73). After excluding patients that required mastectomy following an unsuccessful lumpectomy, ipsilateral breast recurrence rates were 6.3% (8/127) for the touch prep patients after a mean follow up of 4.0 years, 0.0% (0/31) for the gross evaluation patients after a mean follow up of 1.9 years, and 10.5% (4/38) for the patients with no intraoperative assessment after a mean follow up of 3.8 years. Characteristics of each group are listed in Table 1.ConclusionsReexcision for close or positive margins is required for a significant percentage of patients who undergo lumpectomy after a preoperative diagnosis of DCIS on CNB. Although intraoperative TP analysis had the highest success of preventing reexcision, long term data suggest that recurrence rates between intraoperative TP and gross evaluation are both acceptable with short term follow up.Table 1: Characteristics of patients undergoing lumpectomy with a preoperative diagnosis of DCIS on CNBMargin AssessmentTouch PrepGrossNoneFrozenNumber of cases13839531Patient Median Age59.758.956.359.8Cases not needing Reexcision66.7%(92/138)56.4% (22/39)52.8% (28/53)0%(0/1)Cases that received mastectomy8.0%(11/138)20.5%(8/39)26.4%(14/53)100%(1/1)DCIS Grade3- 512- 631- 22Unk- 23- 162- 151- 5Unk- 33-252-201- 7Unk- 13- 02- 01- 1Unk- 0Cases with Necrosis50%(69/138)53.9%(21/39)62.3%(33/53)0%(0/1)Cases upgraded to Invasive Cancer12.3%(17/138)15.4%(6/39)35.9%(19/53)0%(0/1)ReceivedRadiation after lumpectomy85.0%(108/127)67.7% (21/31)76.3%(29/38)0%(0/1)ReceivedTamoxifen after lumpectomy34.7%(44/127)25.8%(8/31)31.2%(12/38)0%(0/1)Ipsilateral breastRecurrence after lumpectomy6.3%(8/127)0%(0/31)10.5% (4/38)0%(0/1)Follow up after lumpectomy (years)4.0(0-10.6)1.9(0.19-5.6)3.8(0.17-9.4)6.0 

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4122.

The Effect of Oncotype Dx® Recurrence Score on Treatment Recommendations for Patients with Early Stage Estrogen Receptor Positive Breast Cancer

Background: Current guidelines recommend administration of chemotherapy for patients with breast carcinomas &gt;1 cm in size, with consideration for patient age, comorbidities and tumor grade. However, it is unknown which patients actually benefit from therapy and overtreatment of a significant proportion of patients is a major concern. We investigated the impact of the Oncotype Dx® Recurrence Score (RS) on chemotherapy recommendations in early stage estrogen receptor (ER) positive breast cancer patients.Methods: We selected 154 patients with early stage ER positive breast cancer and available RS for the study. Clinicopathologic data, including age, menopausal status, tumor size, type, grade, mitotic activity, presence of lymphatic invasion, nodal status, hormone receptor and HER2 status on all patients were provided to four surgical oncologists, four medical oncologists and three pathologists, specializing in breast cancer diagnosis and management. Assuming that all patients were in good general health and would receive endocrine therapy, participants were asked whether they would also advovate adjuvant chemotherapy based on clinicopathologic data with and without knowledge of the RS, and to provide the three salient clinicopathologic features on which their recommendations were based. Changes in recommendations of participants following inclusion of RS data were compared.Results: Based on RS results, 95 (61.7%), 45 (29.2%) and 14 (9.1%) tumors were of low (RS &lt;18), intermediate (RS 18-30) and high (RS ≥31) risk, respectively. The results are summarized in Table 1. Assuming that the hypothesis previously put forward that patients with low to intermediate risk RS are not likely to benefit from chemotherapy, 82.3 ± 1.3% (75.5 - 89.0%) and 69.0 ± 6.9% (5.9 - 85.7%) of patients for whom chemotherapy was recommended by the participants would be "overtreated" without and with the use of RS results (p = 0.0322). No statistically significant difference was found among surgeons, medical oncologists and pathologists. Participants ranked patient age/menopausal status, hormone receptor status and tumor stage/nodal status to be the most important features when recommending chemotherapy.Conclusions: Although current recommendations for adjuvant chemotherapy for early stage ER positive breast cancer patients are largely in line with published guidelines, inclusion of RS alters recommendations in about 25% of cases. While medical oncologists recommended chemotherapy more frequently compared to surgeons and pathologists, they were more likely to change recommendations in light of RS results.Table 1. Summary of results SurgeonsMedical oncologistsPathologistsp* Mean ± SEMRangeMean ± SEMRangeMean ± SEMRange Chemo without RS (%)29.2 ± 1.824.0 - 31.859.0 ± 5.046.8 - 70.846.8 ± 3.741.6 - 53.90.0156Chemo with RS (%)27.0 ± 5.611.0 - 36.438.6 ± 9.517.5 - 63.644.4 ± 5.833.8 - 53.90.1794No change (%)75.3 ± 7.054.5 - 85.766.7 ± 6.851.3 - 83.885.9 ± 6.478.6 - 98.70.3682Add chemo (%)11.2 ± 4.13.2 - 22.76.5 ± 1.93.2 - 11.75.8 ± 3.20.6 - 11.70.6882Avoid chemo (%)13.5 ± 3.94.5 - 22.726.8 ± 7.94.5 - 41.68.2 ± 4.50.6 - 16.20.2186*Kruskal-Wallis test

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4058.

Neoadjuvant Intratumoral Injection of Dendritic Cells in Breast Cancer

Backround: Autologous intratumoral dendritic cell injections were used to modulate the tumor reduction effects of standard neoadjuvant chemotherapy. Dendritic cells are important in the regulation of T cell immunity and have been shown to have activity in cancer patients. The neoadjuavant combination therapy was designed to expose dendritic cells to tumor cell apoptosis leading to induction of tumor antigen-specific responses.Methods: Seventeen women with stage II or III breast cancer with breast tumors at least 3 cm in size and had a confirmed initial breast biopsy were entered into this trial from August 2007 through 2009. All patients participating in the clinical trial had tumors that expressed either carcinoembryonic antigen (CEA) or survivin and were HER2-neu negative. They received 4 cycles of paclitaxel at 175 mg/m2 followed by 4 cycles of doxorubicin 60 mg/m2 and cyclophosphamide 600 mg/m2 (AC) in a bi-weekly dose dense fashion. Pegfilgrastim 6 mg subcutaneous injection was administered 24 hours after each cycle of chemotherapy. Autologous intratumoral dendritic cell injections were administered one week following the first three paclitaxel treatments. All patients consented to a pre-treatment biopsy and a second tumor biopsy after 4 cycles of paclitaxel to evaluate responses to the intratumoral dendritic cell injections. The endpoints of this trial included assessment of clinical and pathologic response in the breast, safety of the intratumoral dendritic cell injection, evaluation of tumor response, and induction of T cell responses to tumor antigens.Results: Fourteen patients are evaluable for response. The median age was 51.5, the median tumor size was 5.6 cm, and 64 % were estrogen receptor positive. A complete clinical response was observed in 57%, a partial response in 36%, and one stable disease response. A pathologic complete response with no evidence of tumor in the breast was confirmed in 2 patients (14 %). Treatment was well tolerated with no incidence of toxicity observed related to the intratumoral dendritic cell injections. Grade 3/4 hematologic toxicity was as expected for the chemotherapy. Other grade 3/4 toxicity related to the chemotherapy included fatigue, hand-foot, infection, mucositis, and hypocalcemia.Discussion: Combination neoadjuvant therapy with dose-dense paclitaxel followed by AC and autologous intratumoral dendritic cell injections administered between the first three cycles of paclitaxel is safe with no toxicity observed related to the intratumoral dendritic cell injections. Immune response to the treatment is being evaluated by proliferation and interferon-gamma production by peripheral blood mononuclear cells in response to tumor cell lysates, survivin, and CEA. Initial evaluation indicates that treatment resulted in generation of tumor specific responses in more than half of all treated patients.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4128.

Male breast cancer: follow-up recommendations after surgery

Abstract #4130

Introduction: National Comprehensive Cancer Network (NCCN) guidelines for female breast cancer treatment and surveillance are well established, but data on male breast cancers are not collected. As an NCCN institution, our objective was to examine practice patterns and follow-up for male breast cancer.&#x2028; Methods: After IRB approval, a prospective breast database from 1990-2008 was queried for male patients. Medical records were examined for traditional factors (TNM, receptor status, treatment, gynecomastia) and follow-up practices such as mammogram use. Survival analysis was performed using the Kaplan-Meier method with 95% confidence intervals (CI) generated for 5-yr estimates. The logrank test was used to compare node positive/negative cohorts.&#x2028; Results: Of the 19,132 patients in the database, 71 (0.4%) were male; 64 had complete data. The median age for the 64 patients was 68.8yrs (range 29-85yrs). 89.1% presented with a palpable mass. 12.5% had gynecomastia in the cancer breast and 9.4% had contralateral gynecomastia. 18/64 (28.1%) had a familial history of breast, ovarian or colon cancer. One patient had bilateral synchronous breast cancer. Seven (10.9%) had previous prostate cancer and 4 (6.25%) had other synchronous cancers (2 papillary thyroid, 2 lung). Genetic testing was offered to all 64; 3 accepted. Two men had contralateral prophylactic mastectomy years later. The mean/median invasive tumor size was 2.0/1.6cm (range 0.0-10.0cm) and all but 2 tumors were ductal. 63 had a mastectomy (65.1% with axillary node dissection; 34.9% with sentinel lymph node biopsy). Lymph node involvement occurred in 25/64 (39.1%). Under NCCN guidelines, 49/64 (76.6%) should receive chemotherapy and chest wall radiation should be given to 27/64 (42.2%) based on tumor size and nodal status. Chemotherapy was offered to 50.0%; 35.9% received chemotherapy. Chest wall radiation was given in 59.3%. 63/64 were ER positive; 49 (77.8%) received hormone therapy. Follow-up annual mammograms were obtained in 27/64 (42.2%)[all BIRADs 1 or 2], not obtained in 28/64 (43.8%), and unknown in 9/64 (14.0%). Median follow-up was 26.1mos (range: 0.26-377.8mos). The 5-yr survival estimates and 95% CI for node positive and negative diseases were 75% (95% CI=46-90%) and 93% (95% CI=74-98%) respectively. For comparison, 5-yr survival rates from the NSABP B-04 trial were 60% in node-positive and 75% in node-negative disease. Four patients (6.3%) died of disease; 10 (15.6%) are alive with distant disease; 47 (73.4%) have no evidence of disease; and 3 (4.7%) are unknown or dead of other causes. There were 2 local recurrences (3.1%) [1 chest wall, 1 in-breast] and no metachronous contralateral breast cancer development. Conclusions: Male breast cancer is uncommon, as is contralateral breast cancer. Men were less likely to receive/accept chemotherapy/hormone therapy/genetic testing/annual mammograms and more likely to receive radiation based on NCCN guidelines, but survival compared to historic females was no worse. Creation of follow-up guidelines for males may be different than females.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4130.