Radiotherapy of Breast Cancer—Professional Guideline 1st Central-Eastern European Professional Consensus Statement on Breast Cancer

The international radiotherapy (RT) expert panel has revised and updated the RT guidelines that were accepted in 2020 at the 4th Hungarian Breast Cancer Consensus Conference, based on new scientific evidence. Radiotherapy after breast-conserving surgery (BCS) is indicated in ductal carcinoma in situ (stage 0), as RT decreases the risk of local recurrence (LR) by 50–60%. In early stage (stage I-II) invasive breast cancer RT remains a standard treatment following BCS. However, in elderly (≥70 years) patients with stage I, hormone receptor-positive tumour, hormonal therapy without RT can be considered. Hypofractionated whole breast irradiation (WBI) and for selected cases accelerated partial breast irradiation are validated treatment alternatives to conventional WBI administered for 5 weeks. Following mastectomy, RT significantly decreases the risk of LR and improves overall survival of patients who have 1 to 3 or ≥4 positive axillary lymph nodes. In selected cases of patients with 1 to 2 positive sentinel lymph nodes axillary dissection can be substituted with axillary RT. After neoadjuvant systemic treatment (NST) followed by BCS, WBI is mandatory, while after NST followed by mastectomy, locoregional RT should be given in cases of initial stage III–IV and ypN1 axillary status.

[Not Available]

The primary aim of AVACONT was to collect data in the course of routine oncological care from patients with metastatic colorectal cancer (mCRC) treated with bevacizumab supplemented fluoropyrimidine-based chemotherapy doublet in an open, multicentre, observational study in Hungary. Primary endpoint of the study was to determine progression-free survival (PFS). The Full Analysis Set (FAS) comprised 280 patients. Median PFS calculated from enrolment was 270 days in the FAS population. The metastatic involvement of the liver or more than one organ significantly decreased (250 and 245 days), while a clinical response achieved significantly increased (partial response: 404, complete response: 623 days) the mPFS calculated from enrolment. PFS calculated from the start of the first-line treatment was significantly decreased by the presence of mutant RAS gene (481 vs. 395 days). The results confirm the efficacy, known prognostic factors and safety profile of bevacizumab in combination with chemotherapy dosed during standard oncology care in Hungarian centres.

Abstract P3-19-24: Long-term follow-up results of intensity modulated radiotherapy in early-stage breast cancer patients

Introduction: Early breast cancer patients with complex anatomy received adjuvant intensity modulated radiotherapy with helical tomotherapy (IMRT-HT) in our Institute. The aim of this study was to evaluate our results in terms of local control, overall survival, progression free survival and adverse events. Materials and methods: This study is a retrospective data analysis, enrolling patients treated with helical tomotherapy irradiation technique. Overall survival (OS) and progression free survival (PFS) curves were plotted with Kaplan-Meier method. We also analyzed the OS and PFS data by molecular subgroups. Long-term toxicities were evaluated using Common Terminology Criteria of Adverse Events (CTCAE) version 4.0. Multivariable analysis was performed to determine the predictors of the toxicities. Results: Between 2009 and 2015, 174 patients with 194 treated breasts were irradiated with helical tomotherapy. The median follow-up was 65 months. The 8-year OS was 89,2 % (IC95: 83.5% - 95.4 %), the 8-year PFS was 85,4% (IC95: 80.2%- 91%). The best therapeutic response shown by the 5 year OS data was in the HER2 receptor positive subroup 95% (IC95: 85.9% - 100%). Long-term skin toxicity was the most common long-term side effect, seen in 20.7% of the patients. 5 patients had second primary breast cancer, always located at the contralateral breast. In multivariant analysis, BMI>25 kg/m2 was found to be a predictor of skin toxicity, and pre-existing cardiovascular disease was independently associated with the risk of cardiovascular toxicity. Conclusion: HT can be safely used for adjuvant breast cancer irradiation. In patients with complex anatomy, HT improves clinical target volume coverage and reduces the dose to OARs. Further prospective studies with long follow-up are needed to confirm and validate these results.

Citation Format: Zita Zolcsák, Pierre Loap, Alain Fourquet, Alexandre Arsene Henry, László Landherr, Péter Hamar, Youlia Kirova. Long-term follow-up results of intensity modulated radiotherapy in early-stage breast cancer patients [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-19-24.

Pathologic Complete Response Rates After Neoadjuvant Pertuzumab and Trastuzumab with Chemotherapy in Early Stage HER2-Positive Breast Cancer - Increasing Rates of Breast Conserving Surgery: A Real-World Experience

Purpose: The neoadjuvant use of pertuzumab and trastuzumab with chemotherapy improves the pathologic complete response (pCR) in early HER2+ breast cancer. The aim of this study was to determine the pCR rate obtained with dual HER2 blockade in routine clinical practice. The secondary and tertiary objective was to investigate the impact of neoadjuvant systemic therapy (NST) on performing breast-conserving surgery and survival data.

Methods: This was a multicentre, retrospective, observational study in patients with stage II and III HER2+ early breast cancer who received pertuzumab and trastuzumab-based NST. Data were collected from patients’ medical records.

Results: Eighty-two patients were included in the study treated in 8 cancer centers in Hungary between March 2015 and January 2020. The study included women with a median age of 50.3 years. The majority of the patients (95%) received a sequence of anthracycline-based chemotherapy followed by docetaxel. pCR was achieved in 54% of the cases. As a result of NST a significant increase of conservative breast surgeries (33% vs. 3.6% planned, p = 0.0001) was observed. Ki67 expression and neutrophil-to-lymphocyte ratio (NLR) significantly predicted pCR. None of the variables were independent predictors of DFS.

Conclusion: The pCR rate achieved in our study demonstrates the reproducibility of trial data in a real-world population. The rate of breast-conserving surgery was significantly increased.

[Secondary lung cancer risk after breast cancer radiation therapy. The benefits substantially overweight the minimal disadvantages]

Considerable evidence supports the rationale for postoperative radiotherapy after breast cancer surgery. Moreover, local tumour control affects survival too. High-dose irradiation is inherently associated with an increased risk of secondary malignancies in the long run. This radiobiological phenomenon raises the question whether it is worth taking this hazard, and the exact level of the risk of a secondary malignancy should be clarified. Answering these questions is important, regarding the large population size of breast cancer survivors, as well as patients' improving survival rates and time. The postoperative radiation load to the ipsilateral lung tissue can be reduced, but it is still significant. The current literature review aims to evaluate the risk of secondary lung cancer associated with breast cancer- specific radiotherapy. Published evidence suggests that the benefits of postoperative radiotherapy following breast cancer surgery are much higher than the minimal risk of secondary lung cancer associated with this management strategy.

[4th Hungarian Breast Cancer Consensus Conference - Radiotherapy guidelines]

The radiotherapy (RT) expert panel revised and updated the RT guidelines accepted in 2016 at the 3rd Hungarian Breast Cancer Consensus Conference based on new scientific evidence. Radiotherapy after breast-conserving surgery (BCS) is indicated in ductal carcinoma in situ (St. 0), as RT decreases the risk of local recurrence (LR) by 50-60%. In early stage (St. I-II) invasive breast cancer RT remains a standard treatment following BCS. However, in elderly (≥70 years) patients with stage I, hormone receptor positive tumour hormonal therapy without RT can be considered. Hypofractionated whole breast irradiation (WBI) and for selected cases accelerated partial breast irradiation are validated treatment alternatives of conventional WBI. Following mastectomy RT significantly decreases the risk of LR and improves overall survival of patients having 1 to 3 or ≥4 positive axillary lymph nodes. In selected cases of patients with 1 to 2 positive sentinel lymph nodes axillary dissection can be substituted with axillary RT. After neoadjuvant chemotherapy (NAC) followed by BCS WBI is mandatory, while after NAC followed by mastectomy locoregional RT should be given in cases of initial stage III-IV and ypN1 axillary status.

Everolimus Plus Exemestane vs Everolimus or Capecitabine Monotherapy for Estrogen Receptor-Positive, HER2-Negative Advanced Breast Cancer: The BOLERO-6 Randomized Clinical Trial

Importance

Everolimus plus exemestane and capecitabine are approved second-line therapies for advanced breast cancer.

Objective

A postapproval commitment to health authorities to estimate the clinical benefit of everolimus plus exemestane vs everolimus or capecitabine monotherapy for estrogen receptor-positive, human epidermal growth factor receptor 2-negative advanced breast cancer.

Design

Open-label, randomized, phase 2 trial of treatment effects in postmenopausal women with advanced breast cancer that had progressed during treatment with nonsteroidal aromatase inhibitors.

Interventions

Patients were randomized to 3 treatment regimens: (1) everolimus (10 mg/d) plus exemestane (25 mg/d); (2) everolimus alone (10 mg/d); and (3) capecitabine alone (1250 mg/m2 twice daily).

Main Outcomes and Measures

Estimated hazard ratios (HRs) of progression-free survival (PFS) for everolimus plus exemestane vs everolimus alone (primary objective) or capecitabine alone (key secondary objective). Safety was a secondary objective. No formal statistical comparisons were planned.

Results

A total of 309 postmenopausal women were enrolled, median age, 61 years (range, 32-88 years). Of these, 104 received everolimus plus exemestane; 103, everolimus alone; and 102, capecitabine alone. Median follow-up from randomization to the analysis cutoff (June 1, 2017) was 37.6 months. Estimated HR of PFS was 0.74 (90% CI, 0.57-0.97) for the primary objective of everolimus plus exemestane vs everolimus alone and 1.26 (90% CI, 0.96-1.66) for everolimus plus exemestane vs capecitabine alone. Between treatment arms, potential informative censoring was noted, and a stratified multivariate Cox regression model was used to account for imbalances in baseline characteristics; a consistent HR was observed for everolimus plus exemestane vs everolimus (0.73; 90% CI, 0.56-0.97), but the HR was closer to 1 for everolimus plus exemestane vs capecitabine (1.15; 90% CI, 0.86-1.52). Grade 3 to 4 adverse events were more frequent with capecitabine (74%; n = 75) vs everolimus plus exemestane (70%; n = 73) or everolimus alone (59%; n = 61). Serious adverse events were more frequent with everolimus plus exemestane (36%; n = 37) vs everolimus alone (29%; n = 30) or capecitabine (29%; n = 30).

Conclusions and Relevance

These findings suggest that everolimus plus exemestane combination therapy offers a PFS benefit vs everolimus alone, and they support continued use of this therapy in this setting. A numerical PFS difference with capecitabine vs everolimus plus exemestane should be interpreted cautiously owing to imbalances among baseline characteristics and potential informative censoring.

Trial Registration

ClinicalTrials.gov identifier: NCT01783444.

[Oral contraception and the risk of breast cancer. Review of the literature]

At present an estimated hundred millions of women worldwide use oral contraception, but the influence of hormonal contraception on carcinogenesis of breast is not fully understood. Previous studies of breast cancer risk show inconsistent findings - from zero elevation to approximately 30%-40% increase in risk. The beneficial effect on ovarian and endometrial cancer risk is apparent. In this literature review we attempt to determine effects of oral contraception in relation to the risk of breast cancer. The risk increased with longer duration of use, but absolute increase is very small. "Beneficial effects of OCs on the gynecological cancers thus outweighed adverse effects." (Vessey).

An open-label, dose-ranging study of Rolontis, a novel long-acting myeloid growth factor, in breast cancer

This randomized, open‐label, active‐controlled study investigated the safety and efficacy of three doses of Rolontis (eflapegrastim), a novel, long‐acting myeloid growth factor, versus pegfilgrastim in breast cancer patients being treated with docetaxel and cyclophosphamide (TC). The primary efficacy endpoint was duration of severe neutropenia (DSN) during the first cycle of treatment. Patients who were candidates for adjuvant/neoadjuvant TC chemotherapy were eligible for participation. TC was administered on Day 1, followed by 45, 135, or 270 μg/kg Rolontis or 6 mg pegfilgrastim on Day 2. Complete blood counts were monitored daily when the absolute neutrophil count (ANC) fell to <1.5 × 10⁹/L. Up to four cycles of TC were investigated. The difference in DSN (time from ANC <0.5 × 10⁹/L to ANC recovery ≥2.0 × 10⁹/L) between the Rolontis and pegfilgrastim groups was −0.28 days (confidence interval [CI]: −0.56, −0.06) at 270 μg/kg, 0.14 days (CI: −0.28, 0.64) at 135 μg/kg, and 0.72 days (CI: 0.19, 1.27) at 45 μg/kg. Noninferiority to pegfilgrastim was demonstrated at 135 μg/kg (P = 0.002) and 270 μg/kg (P < .001), with superiority demonstrated at 270 μg/kg (0.03 days; P = 0.023). The most common treatment‐related adverse events (AEs) were bone pain, myalgia, arthralgia, back pain, and elevated white blood cell counts, with similar incidences across groups. All doses of Rolontis were well tolerated, and no new or significant treatment‐related toxicities were observed. In Cycle 1, Rolontis demonstrated noninferiority at the 135 μg/kg dose and statistical superiority in DSN at the 270 μg/kg dose when compared to pegfilgrastim.

[Alcohol and breast cancer. A short survey]

Regular consumption of alcohol increases the risk of developing (one or more of) several malignant conditions: the frequency of tumours in the aerodigestive tract, in the liver, in the colorectal region and in the breast is increased. The principal carcinogen component of alcoholic drinks is ethanol itself; the effect is unmistakably proportional to the daily/weekly dosage. Under the influence of alcohol-dehydrogenase, ethanol will metabolise to acetaldehyde, which is a known carcinogen. Among other things chronic alcohol consumption promotes the production of endogen hormones, affects the insulin-like growth factor-1, alters several biological pathways, raises oxidative stress, and damages the genes. Even modest daily alcohol intake will increase the risk of breast cancer.

[The post-treatment cognitive impairment ("chemobrain") in breast cancer patients. Short review.]

With the continually growing number of cancer survivors in the past decades there is an increased interest in understanding and treating the adverse events of cancer therapy, which damage the survivor's quality of life. Post-treatment cognitive impairment (chemobrain) is well known in women with breast cancer and other patients with malignancy. The goal of the current short review is to arouse the caregivers' attention to the not severe, but real problem.

[Treatment of bone metastases: bisphosphonates and denosumab]

Some disseminated tumor cells (as "seeds") feel well in the skeletal tissue, as a "soil", but the humoral crosstalk between tumor cells and bone cells disrupts the normal bone homeostasis (remodeling), which leads to a vicious circle, the multiple bone metastatic disease. The tumor cells could stimulate bone resorption, bone neo-formation or both, characteristic of the primary tumor. This usually incurable condition involves serious consequences, as fractures, pain, surgeries, irradiations, plegias, hypercalcemia, etc. (skeletal-related events, SREs), which destroy the quality of life. Targeting bone resorption with bisphosphonates or RANK ligand dependent mechanism could improve the rate of serious SREs and disease-free survival.

The MAGIC survey in hormone receptor positive (HR+), HER2-negative (HER2-) breast cancer: When might multigene assays be of value?

BACKGROUND

A modest proportion of patients with early stage hormone receptor-positive (HR+), HER2-negative (HER2-) breast cancer benefit from adjuvant chemotherapy. Traditionally, treatment recommendations are based on clinical/pathologic criteria that are not predictive of chemotherapy benefit. Multigene assays provide prognostic and predictive information that can help to make more informed treatment decisions. The MAGIC survey evaluated international differences in treatment recommendations, how traditional parameters are used for making treatment choices, and for which patients treating physicians feel most uncertain about their decisions.

METHODS

The MAGIC survey captured respondents' demographics, practice patterns, relevance of traditional parameters for treatment decisions, and use of or interest in using multigene assays. Using this information, a predictive model was created to simulate treatment recommendations for 672 patient profiles.

RESULTS

The survey was completed by 911 respondents (879 clinicians, 32 pathologists) from 52 countries. Chemo-endocrine therapy was recommended more often than endocrine therapy alone, but there was substantial heterogeneity in treatment recommendations in 52% of the patient profiles; approximately every fourth physician provided a different treatment recommendation. The majority of physicians indicated they wanted to use multigene assays clinically. Lack of reimbursement/availability were the main reasons for non-usage.

CONCLUSIONS

The survey reveals substantial heterogeneity in treatment recommendations. Physicians have uncertainty in treatment recommendations in a high proportion of patients with intermediate risk features using traditional parameters. In HR+, HER2- patients with early disease the findings highlight the need for additional markers that are both prognostic and predictive of chemotherapy benefit that may support more-informed treatment decisions.

[Cachexia in cancer patients]

About 50% of all patients with cancer eventually develop anorexia/cachexia syndrome, which represents a complex clinical syndrome occurring in several illnesses, including cancer. The syndrome is characterized by systemic inflammation and primarily loss of body fat and body mass. In this review we shortly summarize the pathomechanism of anorexia/cachexia syndrome and list the current pharmacological approaches.

Capecitabine in Combination with Docetaxel in First Line in HER2-Negative Metastatic Breast Cancer: an Observational Study

Due to the limited experience with capecitabine plus docetaxel (XT) combination in the first-line treatment of metastatic breast cancer in Hungary, the main objective of the study was to analyze the effectiveness and tolerability of XT therapy. A prospective, open-label, non-randomized, single-arm, multicenter, observational study was designed. All female patients were eligible whose metastatic breast cancer could be treated with the XT protocol according to the summary of product characteristics of the drugs. The median progression free survival was 9.9 ± 3.0 months. Time to treatment failure was 4.6 ± 5.1 months on average. The overall response rate was 28.9 %, the clinical benefit rate was 73.3 %. The treatment was discontinued in 35.6 % of patients due to disease progression and in 20.0 % due to adverse events (AE). 33 patients with a total of 73 AEs have been reported, and 13 of them had serious adverse events (SAE). The efficacy and the safety profile of XT chemotherapy proven in the study are consistent with the results demonstrated in randomized trials. First-line XT chemotherapy effectively improves the PFS in metastatic breast cancer.

[3rd Hungarian Breast Cancer Consensus Conference - Radiotherapy Guidelines]

The radiotherapy expert panel revised and updated the radiotherapy (RT) guidelines accepted in 2009 at the 2nd Hungarian Breast Cancer Consensus Conference based on new scientific evidence. Radiotherapy of the conserved breast is indicated in ductal carcinoma in situ (St. 0), as RT decreases the risk of local recurrence by 60%. In early stage (St. I-II) invasive breast cancer RT remains a standard treatment following breast conserving surgery. However, in elderly (≥70 years) patients with stage I, hormone receptor positive tumour hormonal therapy without RT can be considered. Hypofractionated (15×2.67 Gy) whole breast irradiation and for selected cases accelerated partial breast irradiation are validated treatment alternatives of conventional (25×2 Gy) whole breast irradiation. Following mastectomy RT significantly decreases the risk of locoregional recurrence and improves overall survival of patients having 1 to 3 (pN1a) or ≥4 (pN2a, pN3a) positive axillary lymph nodes. In selected cases of patients with 1 to 2 positive sentinel lymph nodes axillary dissection can be omitted and substituted with axillary RT. After neoadjuvant chemotherapy (NAC) followed by breast conserving surgery whole breast irradiation is mandatory, while after NAC followed by mastectomy locoregional RT should be given in cases of initial stage III-IV and ypN1 axillary status.

Abstract P1-10-05: Randomized phase 2, open-label, dose-ranging study of a novel, long-acting G-CSF (SPI-2012) or pegfilgrastim for the management of neutropenia in patients with breast cancer (BC) treated with (Neo) adjuvant chemotherapy with docetaxel + cyclophosphamide (TC)

Background: SPI-2012 is a distinct biologic that uses the innovative proprietary long-acting protein/peptide discovery technology (LAPSCOVERY™) to enhance the activity of G-CSF. SPI-2012 consists of a novel, modified recombinant human G-CSF conjugated to the Fc fragment of IgG4 via a polyethylene glycol linker to produce a new, more potent, longer-acting G-CSF with a potentially unique distribution to areas rich in Fc receptors. To assess the effect of SPI-2012 in supporting patients with breast cancer receiving myelosuppressive chemotherapy with TC, we conducted a randomized Phase 2 study of 3 SPI-2012 doses versus pegfilgrastim.

Methods: This was an open-label, global, multicenter, dose-ranging study designed to compare the safety and efficacy of SPI-2012 relative to a fixed, standard dose of pegfilgrastim as a concurrent active control. The study included 4 treatment arms: 3 dose levels of SPI-2012 (45 μg/kg, 135 μg/kg, and 270 μg/kg) vs pegfilgrastim (6 mg,). The primary objective of the study was the Duration of Severe Neutropenia (DSN) during Cycle 1 in patients with BC who received adjuvant or neoadjuvant TC chemotherapy.

Results: A total of 147 evaluable patients were enrolled. Patient and tumor characteristics were comparable across all 4 treatment arms. Mean age was 58.2 years (range 32 to 77 years); most patients were &lt;65 years (68%), female (98%) and white (95%). The study met its primary endpoint with DSN in patients treated in the 135 µg/kg and 270 µg/kg SPI-2012 treatment arms in Cycle 1 showing non-inferiority to the DSN in patients treated with pegfilgrastim (p=0.002 and p&lt;0.001, respectively). In addition, superiority was demonstrated in patients treated with 270 µg/kg SPI-2012 compared to pegfilgrastim (p=0.023). Non-inferiority in DSN was also observed in Cycles 2 to 4 in both the 135 µg/kg and 270 µg/kg SPI-2012 treatment arms compared to pegfilgrastim.

Duration of Severe Neutropenia in Cycle 1 of TC chemotherapy by Treatment Arm  45 μg/kg SPI-2012 (N=39) 135 μg/kg SPI-2012 (N=36) 270 μg/kg SPI-2012 (N=36)Pegfilgrastim (N=36)DSN Mean (SD)(days)1.03 (1.5)0.44 (1.3)0.03 (0.2)0.31 (0.8)Difference with pegfilgrastim0.720.14-0.28NANon-inferiority p-value0.2960.002&lt;0.001NASuperiority p-value0.0060.5280.023NASD=Standard Deviation; NA=Not Applicable

The common treatment-emergent adverse events observed in ≥20% of patients were similar across all 4 study arms with similar or lower incidence in the SPI-2012 treatment arms, and included fatigue, nausea, alopecia, diarrhea, and bone pain.

Conclusions: All doses of SPI-2012 administered in this Phase 2 study were well tolerated, and no new or significant dose-related toxicities were observed. Most reported adverse events were mild and similar to those previously reported in clinical trials with filgrastim and pegfilgrastim in patients receiving myelosuppressive chemotherapy. In Cycle 1, the 135 µg/kg dose of SPI-2012 was non-inferior compared to pegfilgrastim, and the 270 µg/kg dose was superior in terms of DSN. Additional efficacy and safety data for SPI-2012 will be collected in planned Phase 3 clinical trials.

Citation Format: Vacirca JL, Chan A, Mezei K, Adoo CS, Papai Z, McGregor K, Okera M, Horvath Z, Landherr L, Hanslik J, Hager SJ, Ibrahim EN, Ghazal H, Rostom M, Bhat G, Choi MR, Allen LF, Tedesco KL, Agajanian R, Lang I. Randomized phase 2, open-label, dose-ranging study of a novel, long-acting G-CSF (SPI-2012) or pegfilgrastim for the management of neutropenia in patients with breast cancer (BC) treated with (Neo) adjuvant chemotherapy with docetaxel + cyclophosphamide (TC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-10-05.

[Fulvestrant (Faslodex®) for hormone sensitive breast cancer. A review]

Endocrine agents are well established standards of care in hormone-sensitive postmenopausal breast cancer. The pure estrogen receptor antagonist (down-regulator) fulvestrant after binding to the ER induces its conformational change which disrupts ER signal and accelerates ER degradation. Fulvestrant is devoid of partial agonist activity. In unselected patients there was no difference in TTP between "standard dose" fulvestrant and aromatase inhibitors, but in first-line treatment of advanced breast cancer the elevated dose of fulvestrant may delay progression and may extend the overall survival compared with aromatase inhibitors.

[Historical overview and the current practice of intracavitary treatment of cervical and endometrial cancer in the Oncoradiology Center of Budapest]

The aims of our study were to describe the history and development of intracavitary brachytherapy in the treatment of gynecological tumors, to introduce our current practice for intracavitary brachytherapy treatments based on CT planning. Gynecological intracavitary brachytherapy has been applied in our department since the early 1930s. After a long development it has been completely renewed by 2014. In our center definitive and/or preoperative gynecological HDR-AL brachytherapy treatments were given to 25 patients (13 corpus uterine cancer patients and 12 cervical cancer patients) during the period of 01. 01. 2014-31. 01. 2015. In each case, target volumes were planned by CT images, DVH (dose volume histogram) analysis was performed in order to calculate the radiation tolerance dose of rectum and urinary bladder. Evaluation was performed by the EclipseTM 11.0.47. brachytherapy treatment planning system. During the definitive treatments of the 13 uterine cancer patients the D2cc value related to rectum tolerance was 66.3 GyEQD2 (46-91 Gy). The average D2cc value of urinary bladder tolerance was 76.5 GyEQD2 (30-112 Gy). CI was 0.72 (0.6-0.95). Average value of COIN was 0.57 (0.35-0.78). Compared to the prescribed dose D100 and D90 values were given in ratios. Compared to the volume which receives 100% of reference dose V150 and V200 values were also given in ratios. D100 and D90 were calculated to be 0.66 (0.47-0.97) and 0.91 (0.8-1.25). V150 and V200 volumes were 0.11 (0.04-0.18) and 0.06 (0.02-0.1). During the definitive treatments of 12 cervical cancer patients the D2cc value related to rectum tolerance calculated by DVH was 75.2 GyEQD2 (60-82 Gy). The average D2cc value of urinary bladder tolerance was 85 GyEQD2 based on DVH. CI was 0.66 (0.42-0.76). Average value of COIN was 0.52 (0.32-0.78). Mean value of DHI was 0.46 (0.27-0.54). D100 and D90 were calculated to be 0.72 (0.57-0.89) and 0.91 (0.84-1.11). V150 and V200 volumes were 0.057 (0.02-0.13) and 0.02 (0.002-0.06). During treatments no severe side effects were found. During gynecological intracavitary HDR therapies the calculated dose of the target volume can be given safely using the EclipseTM 11.0.47. brachytherapy planning system and CT-based planning. CT-based treatment planning provides optimal safety for organs at risk, acceptable doses for rectum and urinary bladder while the target volume receives the proper prescribed dose.

Abstract P6-08-06: The multidisciplinary application of genomics in clinical practice (MAGIC) survey: Identification of early stage hormone receptor-positive (HR+), HER2– breast cancer (BC) patients for whom multigene assays may be valuable

Background

Treatment recommendations for early stage HR+, HER2– BC patients depend on many factors. The MAGIC survey evaluated which criteria clinicians use regarding the need for adjuvant chemotherapy (AdjCT) and showed that there was substantial heterogeneity across clinicians and countries in treatment decisions (Aapro et al, EBCC 2014, abstract 24). Multigene assays (MGA) help to make more-informed decisions by providing prognostic and predictive information beyond traditional parameters, but are not always needed. The data presented here show for which BC patient profiles there is a high heterogeneity in treatment recommendations. We suggest that MGAs may be useful to guide treatment recommendations in these cases.

Methods

From August 2013 until January 2014, physicians with ≥5 years’ experience in BC treatment and participating in multidisciplinary teams were invited for the online MAGIC survey. The survey evaluated respondent characteristics and registered treatment recommendations for randomly generated early BC patient profiles (n=672). A conjoint analysis was used to assess which patient attributes were considered for treatment decisions.

Results

The survey was completed by 911 physicians from 52 countries, of whom 72% had &gt;10 years’ experience. Their treatment recommendations showed that for BC patient profiles with only high-risk or only low-risk characteristics, there was a high consensus to recommend AdjCT or no AdjCT (endocrine treatment alone); 42% of the profiles had &gt;75% probability of being recommended AdjCT and 6% had &gt;75% chance of being recommended no AdjCT.

If interactions between patient characteristics were not considered, age was ranked as the most important patient characteristic for AdjCT decisions, followed by tumor grade, tumor size, nodal status, and expression of Ki67, estrogen receptor (ER), and progesterone receptor. The combination of patient attributes and their interactions were, as expected, of importance; some node-positive patients or patients with a Grade 3 tumor had &gt;75% probability to be recommended no AdjCT (eg, older patients or patients with a small [&lt;2 cm] tumor). Conversely, some patients with small, Grade 1 tumors had &gt;75% probability to be recommended AdjCT (eg, young or node-positive patients).

In total, 104 patient profiles (15%) were identified for which treatment recommendations were highly heterogeneous, with a probability of &lt;50% for both an AdjCT treatment recommendation and no AdjCT as a treatment recommendation. These patient profiles tended to have the following characteristics: &gt;50 years old, tumor size &lt;3 cm, Grade 1 or 2 tumor, high ER expression, and Ki67 expression &lt;20%.

Conclusions

There was substantial heterogeneity in treatment recommendations and an overall tendency to give chemo-endocrine rather than endocrine treatment alone. The highest uncertainty in treatment decisions was seen in patients with intermediate risk by clinical and pathological parameters. This opens questions concerning treatment decisions and in such cases MGAs may be most useful.

Citation Format: Matti Aapro, Juan Enrique Bargallo Rocha, Michele De Laurentiis, Roberto Elizalde, László Landherr, Barbro Linderholm, Terry Mamounas, Christos Markopoulos, Miguel Martin, Patrick Neven, Alexander Petrovsky, Dan Rea, Roman Rouzier, Vincent Smit, Christer Svedman, Christoph Thomssen. The multidisciplinary application of genomics in clinical practice (MAGIC) survey: Identification of early stage hormone receptor-positive (HR+), HER2– breast cancer (BC) patients for whom multigene assays may be valuable [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P6-08-06.

[Vitamin D and breast cancer]

The active form of vitamin D, in conjunction with his own receptor, affect a multitude of biological processes in the cell (inter alia it influences the expression of oncogenes and tumor suppressor genes). There is an increasing volume of scientific publications examining the relationships between serum vitamin D levels, vitamin D supplementation and malignant diseases. Some articles suggest inverse relationship between the low serum levels of vitamin D and the breast cancer risk and mortality, whilst other publications do not support this view. Thus the present opinion is conflicted. Vitamin D can exert a beneficial influence on the symptoms and outcomes of a large number of ailments, but its role in affecting cancer is still not completely clear.

[Postoperative radiotherapy of breast cancer and cardiotoxicity]

Cardiac complications may present a particular problem following radiation treatment applied to the mediastinum and thoracic wall (and especially to the left breast). Exposure of the heart during radiotherapy increases the risk of ischemic heart disease occurring generally years after the treatment. The incidence of radiation cardiotoxicity depends on various factors related to oncological therapies and the patient (details of radiotherapy, age, gender, comorbidities, smoking habits, etc.). Until recently the majority of clinical studies reported increased cardiac morbidity in patients receiving radiation treatment of the chest wall and the breast. Due to modern methods, however, postoperative chest wall and left breast irradiation is much safer today than previously. In order to avoid cardiotoxicity, adherence to clinical practice guidelines for chemo- and targeted therapy of breast cancer, use of the most advanced irradiation procedures, regular monitoring of patients, and close cooperation between cardiologists and oncologists are all recommended.

Pathologic assessment of response to chemotherapy in colorectal cancer liver metastases after hepatic resection: which method to use?

BACKGROUND

Patients with metastatic colorectal cancer receive chemotherapy prior liver resection more and more frequently. Histopathologic assessment methods of the resected specimen could evaluate the response to chemotherapy. In this study it is analyzed if these histopathologic changes are specific to preoperative chemotherapy and if these methods have correlation with survival.

METHODS

Sixty three patients with available pathology slides, resected for colorectal cancer liver metastases were enrolled in this study. 46 patients (73%) received neoadjuvant chemotherapy. Five pathological evaluation methods were compared according to the literature: [1] residual tumor cell ratio, [2] tumor regression grade (TRG) scoring system, [3] modified tumor regression grade (mTRG) scoring system with the type of necrosis, [4] pattern of tumor regression and [5] the tumor thickness at the tumor-normal interface (TNI).

RESULTS

Analyzing the pathological methods between the chemotherapy (CTX) and the non-chemotherapy group (NC), we found that that four evaluation methods showed significant and one showed strong correlation with the use of chemotherapy. (Residual tumor cell ratio: p = 0.08; TRG: p <0.01; mTRG: p = 0.03; pattern of tumor regression: p <0.01; TNI: p = 0.02). In the chemotherapy group none of the analyzed pathological methods showed significant correlation with progression free survival (PFS) or with overall survival (OS). Residual tumor cell ratio, TRG and the pattern of tumor cells showed positive but not significant correlation with OS and PFS and a slight difference in the group of patients with TNI <2 mm could be documented.

CONCLUSIONS

Tumor regression grade (TRG) and tumor thickness at the tumor-normal interface (TNI) were the most useful methods for pathological response evaluation and these methods had some correlation with survival. According to these data, authors concluded, that a reproducible and well defined scoring system, based on different histopathological evaluation methods should be developed to predict more accurately the effect of neoadjuvant chemotherapy in CRCLM patients.

[Management of bone metastases]

The skeleton is the most common site to be affected by advanced breast, prostatic, lung, kidney, thyroid and other solid tumors (in addition to myeloma multiplex). Bone metastases cause significant morbidity with nearly always fatal outcome. Over 600 000 new patients diagnosed in the developed countries yearly. On average every 4-6 months patients suffer from series of severe skeletal complications such as pathologic fractures, spinal cord compression, hypercalcemic events, etc., besides the permanent pain. Local external beam radiotherapy, systemic radioisotope-, endocrine-, and chemotherapy, oral and i.v. bisphosphonates and recently s.c. denosumab are the mainstays of treatment, in addition to pain-killers and other usual "classical" interventions. The modern treatments singificantly reduce the probability of skeletal complications and improve the patients' quality of life and, sometimes, they extend the survival as well. The authors briefly summarize the available treatment options.

[The role of PET/CT in decision-making during cancer treatment. Clinical experience]

Nowadays PET/CT examinations have got more and more important role during cancer treatment. It has importance not only in diagnostic examination and staging but also in the radiation planning process and measuring the therapeutic effect. From November 2006 to November 2010 there were 153 PET/CT examinations requested by the Oncology Outpatient Clinic, Uzsoki Hospital. Nine patients were excluded from the examination. In the clinical trial we have aimed to measure what the correlation between the oncologists' questions and the PET/CT results was, in how many cases the PET/CT had influence on therapeutic decision-making. In the case of the patients waiting for the operation we compared the results of the pathological examinations to the results of the PET/CT. The oncologists got the expected answers in 79 cases, while in 45 cases the answers were negative. In 10 cases there were no definite answers. Ten cases proved to be false negative or false positive based on the later pathological examination. As a result of the PET/CT findings the originally planned therapeutic decisions or the therapies in process have been modified in 77 cases. To sum up, the PET/CT gave the expected answers to the oncologists' questions in more than half of the cases (54.9%) and modified the originally prescribed therapy in 53.5% of the cases.

[Aromatase inhibitors and arthralgia]

In several large adjuvant clinical trials it has been demonstrated that substitution (eventually addition) of aromatase inhibitors (AIs) provides an improved outcome of endocrine-sensitive breast cancer over tamoxifen alone. Nevertheless, arthralgia induced by the AIs is one of the most frequent side effects in hormonal therapy. It is characterized by tenosynovial changes and is more frequent in patients in clinical practice than previously appreciated in adjuvant clinical trials. AI-related arthralgia may be related to estrogen deprivation, but estrogen replacement is not an option for these women. Therefore standard painkillers, NSAIDs (COX2 inhibitors), week opioids and other interventions (vitamin D, calcium, bisphosphonates, exercise, acupuncture, complementary and alternative approaches, eventually switch to another endocrine drug) are used for managing this treatment-related side effect, and improve adherence and quality of life among breast cancer survivors.

[The development of the first line treatment of metastatic colorectal cancer (mCRC)]

Chemotherapy options of metastatic colorectal cancer (mCRC) have been progressed rapidly in the last years. Besides of the standard fluorouracil/folinic acid treatment some new active agents (oxaliplatin and irinotecan) have been introduced, and more recently the "targeted" biologicals (bevacizumab, cetuximab, panitumumab) have demonstrated their high effectiveness. This review summarizes the development of the first line treatment of mCRC.

[Chemotherapy of elderly patients with colorectal cancer]

Elderly patients will be the largest group of oncology patients in the future. Because of minimal participation of older patients in randomized clinical trials there is a lack of evidence-based data to make correct decisions with regard to chemotherapy and/or targeted therapy in this age group. Elderly patients have similar benefits from systemic therapies as younger counterparts, but many elders have substantial co-morbidities, which may limit the life expectancy and the effectiveness of systemic therapy. Close collaboration between oncologists and geriatrists will help make decisions on the management of elderly patients suffering from cancer.

Randomized double blind (DB) placebo (Plcb) controlled phase III study assessing the efficacy of xaliproden (X) in reducing the cumulative peripheral sensory neuropathy (PSN) induced by the oxaliplatin (Ox) and 5-FU/LV combination (FOLFOX4) in first-line treatment of patients (pts) with metastatic colorectal cancer (MCRC)

3507

Background: X, an orally administered non-peptide neurotrophic agent developed by sanofi-aventis, was shown in vitro to minimize neuritic damage induced by Ox (co-culture of Schwann cells and dorsal roots ganglia explant). The probability of occurrence of Grade (Gr) 3–4 PSN at a cumulative dose of Ox of 1000 mg/m2, was consistently reported to be of 18–20%. Methods: First line MCRC pts were randomized to receive, in a DB fashion, FOLFOX4 and either Plcb or X 1mg daily. X was administered from the 1st day of chemotherapy till 15 days post last Ox cycle. Co-primary objectives were reduction in the risk of occurrence of Gr 3–4 PSN relative to cumulative dose of Ox (Kaplan-Meier method) and non-inferiority in response rate (RR). Secondary endpoints included evaluation of sensory action potential (SAP) and safety. Results: From July 2002 to May 2004, 649 pts were randomized (324 Plcb, 325 X). Pts characteristics were well balanced across arms, median number of Ox cycles was 12 in both arms, median relative dose intensity (%) was 83.8 (Plcb) and 85.2 (X). A significant risk reduction of 39% in the probability of Grade 3–4 PSN in favor of X was reported (hazard ratio [95% CI] = 0.61 [0.40; 0.93], p= 0.0203). Overall RR [95 % CI] was: Plcb 42.6% [37.1; 48.2] and X 44.9% [39.4; 50.6]. As prospectively defined in the protocol, the lower bound of the CI of the RR ratio above 0.8 confirms noninferiority in RR (1.055 [0.88; 1.26]). In both arms the mean % of change in SAP worsens as a function of PSN severity. 17.3 (Plcb) and 13.5% (X) of the pts discontinued Ox because of PSN. Severe toxicities (% Gr 3–4), reported with a ≥2% difference between arms, were (plcb vs X): diarrhea 10.9 vs 13.0, pulmonary embolism 0.9 vs 3.1, fatigue 3.7 vs 1.5, neutropenia 43.0 vs 37.8. Conclusion: X was shown to be efficient in reducing the risk of Grade 3–4 oxaliplatin-induced PSN without impacting FOLFOX4 antitumor activity.

No significant financial relationships to disclose.

[Pamidronate in the treatment of bone metastases from breast cancer]

Bone metastases afflict over 70% of patients with advanced breast cancer, resulting in impaired quality of life and significant clinical problems. Until appearance of the bisphosphonates there was no specific therapeutic treatment available to manage the symptoms of osteolytic bone metastases. Bisphosphonates are stable chemical analogues of pyrophosphate, and inhibit osteoclast-mediated bone resorption, the treatment is effective in reducing skeletal morbidity in breast cancer with fewer skeletal related events, reduced pain and analgesic consumption, and improved quality of life. As a result, bisphosphonates should now be part of the routine management of metastatic bone disease and multiple myeloma. Promising data have resulted in considerable interest in the possible adjuvant use of bisphosphonates. Pamidronate is an easy to use potent inhibitor of osteolysis, given in conjunction with standard anticancer therapies effectively relieves bone pain and improves performance status. Monthly pamidronate infusions for one or two years in addition to standard anticancer therapy reduce by more than one third the yearly frequency of skeletal-related events. The authors report their practice in which 119 breast cancer patients metastatic to bone received 90-120 mg pamidronate infusion/cycle in addition to standard breast cancer therapy every 3-4 weeks.

[Radiotherapy of benign disorders]

The radiation oncologist's primary concern is treatment of patients with malignant tumors but sometimes faces on occasion rare, non malignant disorders. The scarcity of disease incidence is reflected by the paucity of references for these diseases in the literature. This minimal exchange of information may make research and analysis difficult, tedious and not easily directed. Even with recognition of the risks of late skin injury, carcinogenesis, leukemogenesis and genetic damage from all ionizing radiation, radiation therapy also continues to be accepted treatment for benign diseases that do not respond to other methods of therapy. The purpose of this paper is to provide a short overview of the radiotherapy of most frequent benign disorders.

[Radiation moulage therapy of gingival tumors]

An irradiation treatment technique, long ago known yet seldom employed, is reported on. With a patient, because of an inoperable gingiva-tumor, after percutan irradiation for complementary purpose radium-moulage treatment was employed. Due to the irradiation treatment the patient became symptomless.