Abstract OT1-04-03: Sentinel lymph node biopsy versus no axillary surgery in early breast cancer clinically and ultrasonographically node negative: A multicentre prospective randomized controlled trial (VENUS trial)

Background: In early breast cancer, sentinel lymph node biopsy (SLNB) has become the gold standard of axillary evaluation. Although it has less morbidity than axillary lymph node dissection, it may still cause sequelae. Currently, patients selection for SNB has been through physical examination, but presents low sensitivity and high false negative rate. Thus, ultrasonography with biopsy of suspected lymph nodes increases the accuracy. In an attempt to further reduce the morbidity of axillary surgery, it was hypothesized that it would be possible to avoid SLNB in women with early breast cancer. The aim of this study is to compare the SLNB with no axillary surgery as an approach to the axilla in early breast cancer and negative axilla clinical and ultrasonographical. Our trial includes some subsets excluded in others similar ongoing trials: patients that will undergo mastectomy and will receive primary systemic therapy. Trial design: A multicenter, phase III, prospective, open-label, non-inferiority randomized clinical trial, including 10 study sites in Brazil that will randomize 800 early breast cancer patients.Eligibility criteria: Inclusion: woman, age ≥ 18 years, histologic diagnostic of breast carcinoma, tumor ≤ 5 cm (T1 and T2) in all exams, clinically node-negative, ultrasound node-negative or negative core biopsy/fine needle aspiration if suspect lymph node (in this situation is mandatory lymph node tissue in pathologic exam). Exclusion: metastatic disease in biopsy or image before treatment, pregnancy, breastfeed, previous diagnostic of invasive neoplasia (excluding skin cancer no melanoma). It will be allowed mastectomy and neoadjuvant treatment if patient has negative axilla and T1-2 pre-systemic therapy.Intervention and stratification: Participants in experimental group will not be undergo axillary surgery and in control group will be submitted at SLNB. The randomization will be 1:1 ratio and stratified by: tumor size (T1 and T2) and age (≥50 and < 50 years)Specific aims: the primary objective is to access whether omission of axillar surgery is not inferior than SLNB in term of disease-free survival (DFS) at 5 years (primary endpoint). Secondary endpoints are overall survival, locoregional free survival, axillary recurrence rate, to describe surgical early and later complications and to evaluate costs of procedure SLNB or no. Statistical methods: with type I error 5%, power 80% and risk ratio 0.8, considering DFS at 5 years 90% in control group non-inferior DFS at 5 years 85% in experimental group, it was calculated sample size of 400 patients randomized and with follow up in each group (lost estimated 10%). Chi-squares and Fisher's tests will be used for the univariate analyzes, and logistic regression models for adjusted analyzes. Disease-free survival analysis, disease-free survival at a distance, and overall survival will be performed, which will be compared between groups using Kaplan-Meyer curves, log-rank tests and Cox Proportional Hazards-adjusted analyzes. The analyzes will be made intention-to-treat and per protocol.Present and target accrual: the trial was activated at November 2019 and 92 patients were accrued on July 7th 2021. The estimative of finish recruitment is in 2025 and the first data analyses will be made in 2029. The trial is registered in ReBEC (Brazilian register): RBR-8g6jbf. Contact information: Prof. Dr. Giuliano Duarte, - Univertidade Estadual de Campinas - CAISM - UNICAMP, giulianomduarte@gmail.com

Citation Format: Giuliano Mendes Duarte, Danielle Cristina Myiamoto Araújo, Rodrigo Menezes Jales, Júlia Yoriko Shinzato, Cassio Cardoso Filho, Renato Zocchio Torresan, Fabrício Palermo Brenelli, Maria Beatriz de PaulaLeite Kraft, Sergio Carlos Barros Esteves, Luis Otávio Zanatta Sarian, Rosemar MecedoSousa Rahal, Ruffo de Freitas, Jr, Eduardo Carvalho Pessoa, Clecio Ênio Murta Lucena, Andrea PiresSouto Damin, Jorge Villanova Biazus, Vinicius Milani Budel, Idan de Oliveira, Jr, Rene Aloisio da Costa Vieira, Júlio César Narciso Gomes. Sentinel lymph node biopsy versus no axillary surgery in early breast cancer clinically and ultrasonographically node negative: A multicentre prospective randomized controlled trial (VENUS trial) [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 OT1-04-03.

High Expression of SOD2 Protein Is a Strong Prognostic Factor for Stage IIIB Squamous Cell Cervical Carcinoma

High superoxide dismutase 2 (SOD2) expression is associated with a poor prognosis at many cancer sites, the presence of metastases, and more advanced cervical cancer. This study aims to determine whether SOD2 protein expression is associated with the prognosis of stage IIIB cervical carcinoma. Methods: sixty-three patients with stage IIIB squamous cell cervical carcinoma were included. The evaluation of SOD2 expression by immunohistochemistry was based on a positive cell ratio score and the staining intensity score. Taking disease recurrence and death as endpoints, receiver operating characteristic curves were used to discriminate between high and low SOD2 expression. Results: high SOD2 expression was associated with recurrence (p = 0.001), distant recurrence (p = 0.002), and death (p = 0.005). A multivariate analysis showed that patients with high SOD2 expression had a threefold increased risk for recurrence (HR = 3.16; 1.33–7.51) and death (HR = 2.98; 1.20–7.40) compared with patients who had low SOD2 expression. Patients with high SOD2 expression had shorter disease-free survival (p = 0.001) and overall survival (p = 0.003) than patients with low SOD2 expression. Conclusion: high SOD2 expression is a strong prognostic factor for stage IIIB squamous cell carcinoma of the cervix and could be used as a prognostic marker in women with cervical carcinoma.

Development of a Ki-67-based clinical trial assay for neoadjuvant endocrine therapy response monitoring in breast cancer

PURPOSE

The recent publication of the ACOSOG Z1031 trial results demonstrated that Ki-67 proliferation marker-based neoadjuvant endocrine therapy response monitoring could be used for tailoring the use of adjuvant chemotherapy in ER+HER2-negative breast cancer patients. In this paper, we describe the development of the Ki-67 clinical trial assay used for this study.

METHODS

Ki-67 assay assessment focused on reproducing a 2.7% Ki-67 cut-point (CP) required for calculating the Preoperative Endocrine Prognostic Index and a 10% CP for poor endocrine therapy response identification within the first month of neoadjuvant endocrine treatment. Image analysis was assessed to increase the efficiency of the scoring process. Clinical outcome concordance for two independent Ki-67 scores was the primary performance metric.

RESULTS

Discordant scores led to a triage approach where cases with complex histological features that software algorithms could not resolve were flagged for visual point counting (17%). The final Ki-67 scoring approach was run on T1/2 N0 cases from the P024 and POL trials (N = 58). The percent positive agreement for the 2.7% CP was 87.5% (95% CI 61.7-98.5%); percent negative agreement 88.9% (95% CI: 65.3-98.6%). Minor discordance did not affect the ability to predict similar relapse-free outcomes (Log-Rank P = 0.044 and P = 0.055). The data for the 10% early triage CP in the POL trial were similar (N = 66), the percentage positive agreement was 100%, and percent negative agreement 93.55% (95% CI: 78.58-99.21%). The independent survival predictions were concordant (Log-rank P = 0.0001 and P = 0.01).

CONCLUSIONS

We have developed an efficient and reproducible Ki-67 scoring system that was approved by the Clinical Trials Evaluation Program for NCI-supported neoadjuvant endocrine therapy trials. Using the methodology described here, investigators are able to identify a subgroup of patients with ER+HER2-negative breast cancer that can be safely managed without the need of adjuvant chemotherapy.

[The new classification of breast cancers: finding the luminal A]

PURPOSE

To compare the distributions of patients with clinical-pathological subtypes of luminal B-like breast cancer according to the 2011 and 2013 St. Gallen International Breast Cancer Conference Expert Panel.

METHODS

We studied 142 women with breast cancer who were positive to estrogen receptor and had been treated in São Paulo state, southeast Brazil. The expression of the following receptors was assessed by immunohistochemistry: estrogen, progesterone (PR) and Ki-67. The expression of HER-2 was measured by fluorescent in situ hybridization analysis in tissue microarray.

RESULTS

There were 29 cases of luminal A breast cancers according to the 2011 St. Gallen International Breast Cancer Conference Expert Panel that were classified as luminal B-like in the 2013 version. Among the 65 luminal B-like breast cancer cases, 29 (45%) were previous luminal A tumors, 15 cases (20%) had a Ki-67 >14% and were at least 20% PR positive and 21 cases (35%) had Ki-67 >14% and more than 20% were PR positive.

CONCLUSIONS

The 2013 St. Gallen consensus updated the definition of intrinsic molecular subtypes and increased the number of patients classified as having luminal B-like breast cancer in our series, for whom the use of cytotoxic drugs will probably be proposed with additional treatment cost.

Bayesian Estimation of Performance Measures of Cervical Cancer Screening Tests in the Presence of Covariates and Absence of a Gold Standard

In this paper we develop a Bayesian analysis to estimate the disease prevalence, the sensitivity and specificity of three cervical cancer screening tests (cervical cytology, visual inspection with acetic acid and Hybrid Capture II) in the presence of a covariate and in the absence of a gold standard. We use Metropolis-Hastings algorithm to obtain the posterior summaries of interest. The estimated prevalence of cervical lesions was 6.4% (a 95% credible interval [95% CI] was 3.9, 9.3). The sensitivity of cervical cytology (with a result of ≥ ASC-US) was 53.6% (95% CI: 42.1, 65.0) compared with 52.9% (95% CI: 43.5, 62.5) for visual inspection with acetic acid and 90.3% (95% CI: 76.2, 98.7) for Hybrid Capture II (with result of >1 relative light units). The specificity of cervical cytology was 97.0% (95% CI: 95.5, 98.4) and the specificities for visual inspection with acetic acid and Hybrid Capture II were 93.0% (95% CI: 91.0, 94.7) and 88.7% (95% CI: 85.9, 91.4), respectively. The Bayesian model with covariates suggests that the sensitivity and the specificity of the visual inspection with acetic acid tend to increase as the age of the women increases.

The Bayesian method proposed here is an useful alternative to estimate measures of performance of diagnostic tests in the presence of covariates and when a gold standard is not available. An advantage of the method is the fact that the number of parameters to be estimated is not limited by the number of observations, as it happens with several frequentist approaches. However, it is important to point out that the Bayesian analysis requires informative priors in order for the parameters to be identifiable. The method can be easily extended for the analysis of other medical data sets.

Bayesian estimation of performance measures of cervical cancer screening tests in the presence of covariates and absence of a gold standard

In this paper we develop a Bayesian analysis to estimate the disease prevalence, the sensitivity and specificity of three cervical cancer screening tests (cervical cytology, visual inspection with acetic acid and Hybrid Capture II) in the presence of a covariate and in the absence of a gold standard. We use Metropolis-Hastings algorithm to obtain the posterior summaries of interest. The estimated prevalence of cervical lesions was 6.4% (a 95% credible interval [95% CI] was 3.9, 9.3). The sensitivity of cervical cytology (with a result of >or= ASC-US) was 53.6% (95% CI: 42.1, 65.0) compared with 52.9% (95% CI: 43.5, 62.5) for visual inspection with acetic acid and 90.3% (95% CI: 76.2, 98.7) for Hybrid Capture II (with result of >1 relative light units). The specificity of cervical cytology was 97.0% (95% CI: 95.5, 98.4) and the specificities for visual inspection with acetic acid and Hybrid Capture II were 93.0% (95% CI: 91.0, 94.7) and 88.7% (95% CI: 85.9, 91.4), respectively. The Bayesian model with covariates suggests that the sensitivity and the specificity of the visual inspection with acetic acid tend to increase as the age of the women increases. The Bayesian method proposed here is an useful alternative to estimate measures of performance of diagnostic tests in the presence of covariates and when a gold standard is not available. An advantage of the method is the fact that the number of parameters to be estimated is not limited by the number of observations, as it happens with several frequentist approaches. However, it is important to point out that the Bayesian analysis requires informative priors in order for the parameters to be identifiable. The method can be easily extended for the analysis of other medical data sets.

Variants of human papillomavirus types 16 and 18: histological findings in women referred for atypical glandular cells or adenocarcinoma in situ in cervical smear

Human papillomavirus (HPV) genotypes cannot fully explain the histological diagnosis of women with glandular abnormalities detected by cervical smear. Thus, this study was designed to analyze the distribution of HPV-16 and HPV-18 variants in women referred because of atypical glandular cells and adenocarcinoma in situ in their cervical smears and its association with histological results. Twenty-four women with HPV-16 and 6 with HPV-18, selected from 160 women with cervical smears suggestive of glandular abnormalities, were included. Histological results showed cervicitis (1 case), squamous neoplasia (18 cases), glandular neoplasia (7 cases), and glandular neoplasia associated with a squamous component (4 cases). Among the 24 cases presenting HPV-16, the European variant was detected in 15 (62%) and the Asian American in 9 (38%). Among the 15 cases associated with the European variant, 14 (93%) presented squamous neoplasia and 1 (7%) invasive adenocarcinoma. Asian-American HPV-16 variants were significantly associated with histological diagnosis of glandular neoplasia alone (odds ratio, 9.3 [1.4-60.2]) or associated with squamous neoplasia (odds ratio, 18.7 [1.5-232.3]). Adenocarcinomas were detected in 4 of 6 HPV-18-positive cases, being 2 cases had the European variant, 1 had the Asian Amerindian variant, and 1 had the African variant. The association of HPV-16 with squamous or glandular neoplasia is explained by its variants. In this study, squamous neoplasia was related to the European variant of HPV-16, whereas glandular neoplasia was related to the Asian-American variant. Glandular neoplasia is associated with HPV-18, but the results of our analysis of its variants were inconclusive.

Prediction of high-grade cervical disease with human papillomavirus detection in women with glandular and squamous cytologic abnormalities

The objective of this study was to assess whether human papillomavirus (HPV) detection with hybrid capture II (HC II) can help predict the presence and the nature, glandular or squamous, of histologic cervical lesions in women referred due to atypical glandular cells (AGC) or high-grade squamous intraepithelial lesion (HSIL). A total of 247 women were included. Referral Pap smears comprised AGC (51 cases), AGC plus HSIL (28 cases), adenocarcinoma in situ (10 cases), and HSIL (158 cases). All patients were tested for high-risk HPV with HC II and had a histologic assessment of their cervix. Histologic analysis showed 38 women with (15.3%) cervicitis, 194 with (75.5%) squamous lesions, and 15 with (9.2%) glandular neoplasia. The overall rate of high-risk HPV detection was 77%. Almost 70% of AGC-HPV-negative patients did not have a pathologically proven cervical neoplasia, whereas 76% of women with AGC-HPV-positive result were diagnosed with a squamous or glandular neoplasia. Most (95%) of the lesions in patients with AGC-HSIL were of squamous nature, and HPV detection did not contribute to their differentiation from glandular lesions. We conclude that in women with AGC, HPV positivity strongly correlated with the presence of glandular or squamous cervical lesion but did not help distinguishing women with squamous from those with glandular neoplasia.

Citologia oncológica, captura de híbridos II e inspeção visual no rastreamento de lesões cervicais

Avaliar as alterações na citologia oncológica, na captura híbrida II e na inspeção visual com ácido acético (IVA) a 5% em 684 mulheres atendidas em uma unidade de saúde, e avaliar o desempenho e a concordância entre os exames. Procurar descrever as características sócio-demográficas e reprodutivas (SDR) destas mulheres e sua associação com a presença de doença. As mulheres foram submetidas à coleta de citologia, captura e IVA, e as com exame positivo foram submetidas à colposcopia com biopsia, se necessário. Foi calculado o desempenho dos testes e a associação dos fatores SDR com o diagnóstico histológico foi avaliada por intermédio do cálculo do odds ratio. Embora 198 mulheres apresentassem pelo menos um teste alterado, apenas 21 apresentaram lesão histológica. A sensibilidade dos testes foi semelhante enquanto as especificidades da IVA e da citologia foram maiores que a da captura híbrida II. Apenas a ausência de citologia esteve associada à presença de doença. O desempenho da citologia foi maior que o da IVA, que foi maior que o da captura. A ausência de citologia foi associada com doença histológica.