Ten-year results of intense dose-dense chemotherapy show superior survival compared with a conventional schedule in high-risk primary breast cancer: final results of AGO phase III iddEPC trial

Background

Primary breast cancer (BC) patients with extensive axillary lymph-node involvement have a limited prognosis. The Arbeitsgemeinschaft fuer Gynaekologische Onkologie (AGO) trial compared intense dose-dense (idd) adjuvant chemotherapy with conventionally scheduled chemotherapy in high-risk BC patients. Here we report the final, 10-year follow-up analysis.

Patients and methods

Enrolment took place between December 1998 and April 2003. A total of 1284 patients with 4 or more involved axillary lymph nodes were randomly assigned to receive 3 courses each of idd sequential epirubicin, paclitaxel and cyclophosphamide (iddEPC) q2w or standard epirubicin/cyclophosphamide followed by paclitaxel (EC → P) q3w. Event-free survival (EFS) was the primary end point.

Results

A total of 658 patients were assigned to receive iddEPC and 626 patients were assigned to receive EC → P. The median duration of follow-up was 122 months. EFS was 47% (95% CI 43% to 52%) in the standard group and 56% (95% CI 52% to 60%) in the iddEPC group [hazard ratio (HR) 0.74, 95% CI 0.63-0.87; log-rank P = 0.00014, one-sided]. This benefit was independent of menopausal, hormone receptor or HER2 status. Ten-year overall survival (OS) was 59% (95% CI 55% to 63%) for patients in the standard group and 69% (95% CI 65% to 73%) for patients in the iddEPC group (HR = 0.72, 95% CI 0.60-0.87; log-rank P = 0.0007, two-sided). Nine versus two cases of secondary myeloid leukemia/myelodysplastic syndrome were observed in the iddEPC and the EC → P arm, respectively.

Conclusion

The previously reported OS benefit of iddEPC in comparison to conventionally dosed EC → P has been further increased and achieved an absolute difference of 10% after 10 years of follow-up.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Reversible Stadien intravaskulärer Gerinnung und ihre Auswirkungen auf Nierenfunktion und Urokinaseausscheidung

Weiblichen Kaninchen wurde physiologische Kochsalzlösung, Thrombinlösung, Trasylol-Lösung und Trasylol-Thrombin gemeinsam infundiert. Hierbei waren nach Infusion von Thrombin und von Thrombin-Trasylol im Plasma wie in Gewebsschnitten Fibrinmonomere nachweisbar. Eine disseminierte intravaskuläre Gerinnung war bei den Tieren, die Thrombin-Trasylol kombiniert erhielten, deutlicher ausgeprägt als bei den Tieren, die nur Thrombin erhielten. Ein primär polyurisches akutes Nierenversagen war nur bei den Tieren nachweisbar, die Thrombin-Trasylol erhalten hatten. Tiere, die Thrombin erhalten hatten, wiesen gegenüber Kontrollgruppen eine relative Verminderung der Urokinaseausscheidung pro Minute im Urin auf. Die glomerulären Fibrinniederschläge werden während des Versuchszeitraumes von 20 Std. wieder aufgelöst und die beobachteten Veränderungen kehren gegen Versuchsende zu den Ausgangswerten zurück. Darüber hinaus kann im Urin spontan eine Inhibitoraktivität gegenüber Plasmin oder Piasminogenaktivator beobachtet werden, deren Ausscheidung mit steigenden Konzentrationsleistungen der Niere zunimmt. Nach Trasylol-Infusion tritt eine Inhibitoraktivität im Urin häufiger und in stärkerem Ausmaß auf, als dies spontan der Fall ist.

Die Annahme erscheint gerechtfertigt, daß reversible Stadien der disseminierten in tra va skulären Gerinnung, deren Quantität und Dauer vermindert ausgeprägt sind, Urokinaseausscheidung und Nierenfunktion vorübergehend beeinträchtigen, wobei die Veränderungen bei Wiederauflösung der Gerinnsel rückläufig sind.

Verbrauchskoagulopathie und Lysekoagulopathie bei menschlichen Äquivalenten des Sanarelli-Shwartzman-Phänomens (generalisiertes Shwartzman-Phänomen)

Es wird über einen Fall von Chorionamnionitis am Ende der Gravidität berichtet. Gerinnungsanalytische und histologische Befunde liegen vor. Die klinischen, gerinnungsanalytischen und histologischen Befunde stützen die Hypothese, daß am Beginn der pathogenetischen Kette eine intravasale Verbrauchsreaktion steht, der in wechselnden Zeitabständen eine Piasminaktivität unterschiedlicher Intensität folgt. Als Kriterien der Verbrauchskoagulopathie wurden eine Verminderung der Thrombozyten und einzelner Plasmafaktoren angesehen. Als Kriterien der Lysekoagulopathie wurden die typischen Kurven im Thrombelastogramm in Verbindung mit dem Nachweis des sogenannten Antithrombin VI und eines Antithromboplastin angesehen. Die Zeichen der generalisierten intravasalen Gerinnung mit nachfolgender Lyse der fibrinreichen Gerinnsel waren im histologischen Bild gleichermaßen zu erkennen. Das therapeutische Vorgehen orientierte sich an diesem zweiphasigen Verlauf.

Retikuloendotheliale Clearance intravasaler Fibrinmonomere in der Milz

Thrombin induziert in Gegenwart des Fibrinolyseinhibitors Trasylol eine disseminierte intravasale Gerinnung. Das Schicksal der hierbei im Plasma auftretenden Fibrinmonomere wurde mit dem Alkoholtest zum Nachweis plasmatischer Fibrinmonomere und morphologischen Untersuchungen an alkohol- und formalinfixierten Organen verfolgt. Fibrinmonomere werden nach Alkoholfixierung bei nichtblockiertem RES als perizelluläre büschelförmige mizellare Strukturen in der Umgebung der Sinus -endothelien und Retikulumzellen der Milz sichtbar. Die perizelluläre Präzipitation wird als morphologischer Ausdruck der Oberflächenadsorption der Monomere an nicht blockierten Sinusendothelien und Retikulumzellen verständlich. Bei blockiertem RES geht diese perizelluläre Präzipitation verloren, die prolongiert im Blute kreisenden Monomere werden intravasal ohne Beziehung zu RES-Zellen durch Alkohol geliert und als kondensierte Präzipitate sichtbar. Sie lassen sich dann morphologisch nicht mehr von typischen fibrinreichen intravasalen Gerinnseln unterscheiden. In Formalin -schnitten werden dagegen ausschließlich bereits in vivo hochpolymere Fibrinformen erfaßbar. Mit dem lichtmikroskopischen Nachweis artefiziell aggregierter Fibrinmonomere an der Oberfläche der Zellen des retikuloendothelialen Systems der Milz schlagen die vorliegenden Untersuchungen eine Brücke zwischen den laborchemischen Befunden am Plasma bei Verbrauchsreaktionen und elektronenmikroskopischen Ergebnissen.

Morphologischer Nachweis von Fibrinmonomeren im histologischen Schnitt

Der Alkoholtest nach Godal und Abildgaard gestattet den Nachweis plasmatischer Fibrinmonomere im klinischen Schnelltest. In vergleichenden gerinnungsanalytischen und patho-anatomischen Untersuchungen zum tierexperimentellen Sanarelli-Shwartz-man-Phänomen und seinen Modifikationen wird der Nachweis erbracht, daß niedrige Alkoholkonzentrationen auch im histologischen Schnitt zu einer Aggregation und Polymerisation präexistenter plasmatischer Fibrinmonomere führen. Im Rahmen einer generalisierten intravasalen Gerinnung mit Faktorenverbrauch auftretende Fibrinmonomere werden bei Alkoholfixierung aggregiert und in Gegenwart eines auch in vitro aktiven FSF (Faktor XIII) sekundär stabilisiert. Nach Hemmung dieser Stabilisierungsreaktion durch Benzamidin, p-Chlormercuribenzoat, Glyzin-Methyl-ester und Zystein führt niedrigprozentiger Alkohol dagegen nur zu einer Fibrinaggregation. Formalinfixierung vermag zwar Fibrinaggregate über Ausbildung von Methylenbrücken zu stabilisieren, führt indessen nicht zu einer Aggregation präexistenter Fibrinmonomere. Vergleichende Untersuchungen nach Alkohol- und Formalinfixierung gestatten damit eine Aussage über präexistente Thrombinaktivitäten und präexistente plasmatische Fibrinmonomere. Sie sind geeignet, die Aussagekraft patho-anatomischer Untersuchungen selbst bei unterschwelligen intravasalen Gerinnungs-vorgängen wesentlich zu verbessern. Fibrin- und Fibrinogenspaltprodukte haben auf die Alkohol-induzierte Aggregation präexistenter Fibrinmonomere offenbar keinen Einfluß.

A New Approach to Phenotyping Disseminated Tumor Cells: Methodological advances and Clinical Implications

At the time of primary therapy (surgery, systemic chemotherapy and/or radiation), disseminated tumor cells in the bone marrow can be found in almost one-third of patients with cancer of the breast, ovary, esophagus, stomach, colon, and other solid tumors. Whereas the prognostic impact of the mere presence of these cells is still a matter of debate, it has been shown that expression of tumor-associated antigens in disseminated tumor cells is linked to more aggressive disease. Therefore, further characterization of disseminated tumor cells at the protein and gene level has become increasingly important. To date, the most common detection method for disseminated tumor cells in the bone marrow is an immunocytochemical approach using cytokeratin-directed antibodies for detection of epithelial cells and the APAAP system for their visualization. We have established a new double immunofluorescence technique enabling simultaneous detection, phenotyping, and antigen quantification of disseminated tumor cells. Mononuclear cells from bone marrow are enriched by Ficoll gradient centrifugation and cytospins are prepared. Double immunofluorescence is performed using antibodies against cytokeratins 8/18/19 (mAb A45B/B3) and the uPA receptor CD87 (pAb HU277). CD87 expression is recorded by confocal laser scanning microscopy (CLSM) using fluorescence labeled latex beads as the reference; staining intensities of all the scans are then summed and quantified (extended focus). This protocol, originally designed for disseminated tumor cells in bone marrow, can also be applied to disseminated tumor cells in blood, to leukapheresis cells or to cells present in malignant ascites or other malignant effusions. The tumor cells detected may be used for gene and mRNA analyses. Furthermore, disseminated tumor cells also represent interesting targets for clinical studies on patient prognosis or prediction of therapy response as well as for specific tumor-biological therapies.

The role of auditory feedback in music-supported stroke rehabilitation: A single-blinded randomised controlled intervention

PURPOSE

Learning to play musical instruments such as piano was previously shown to benefit post-stroke motor rehabilitation. Previous work hypothesised that the mechanism of this rehabilitation is that patients use auditory feedback to correct their movements and therefore show motor learning. We tested this hypothesis by manipulating the auditory feedback timing in a way that should disrupt such error-based learning.

METHODS

We contrasted a patient group undergoing music-supported therapy on a piano that emits sounds immediately (as in previous studies) with a group whose sounds are presented after a jittered delay. The delay was not noticeable to patients. Thirty-four patients in early stroke rehabilitation with moderate motor impairment and no previous musical background learned to play the piano using simple finger exercises and familiar children's songs.

RESULTS

Rehabilitation outcome was not impaired in the jitter group relative to the normal group. Conversely, some clinical tests suggests the jitter group outperformed the normal group.

CONCLUSIONS

Auditory feedback-based motor learning is not the beneficial mechanism of music-supported therapy. Immediate auditory feedback therapy may be suboptimal. Jittered delay may increase efficacy of the proposed therapy and allow patients to fully benefit from motivational factors of music training. Our study shows a novel way to test hypotheses concerning music training in a single-blinded way, which is an important improvement over existing unblinded tests of music interventions.

Comparison of prognostic and predictive impact of genomic or central grade and immunohistochemical subtypes or IHC4 in HR+/HER2- early breast cancer: WSG-AGO EC-Doc Trial

INTRODUCTION

Potential prognostic and predictive markers in early, intermediate-risk breast cancer (BC) include histological grade, Ki-67, genomic signatures, e.g. genomic grade index (GGI), and intrinsic subtypes. Their prognostic/predictive impact in hormone receptor (HR: ER and/or PR) positive/HER2- BC is controversial. WSG-AGO EC-Doc demonstrated superior event-free survival (EFS) in patients with 1-3 positive lymph node receiving epirubicin/cyclophosphamide-docetaxel (EC-Doc) versus 5-fluoruracil/epirubicin/cyclophosphamide (FEC).

METHODS

In a representative trial subset, we quantify concordance among factors used for clinical chemotherapy indication. We investigate the impact of central histology (n = 772), immunohistochemistry for intrinsic subtyping and IHC4, and dichotomous (GG) or continuous (GGI) genomic grade (n = 472) on patient outcome and benefit from taxane chemotherapy, focusing on HR+/HER2- patients (n = 459).

RESULTS

Concordance of local grade (LG) with central (CG) or genomic grade was modest. In HR+/HER2- patients, low (GG-1: 16%), equivocal (GG-EQ: 17%), and high (GG-3: 67%) GG were associated with respective 5-year EFS of 100%, 93%, and 85%. GGI was prognostic for EFS within all LG subgroups and within CG3, whereas IHC4 was prognostic only in CG3 tumors.In unselected and HR+/HER2- patients, CG3 and luminal-A-like subtype entered the multivariate EFS model, but not IHC4 or GG. In the whole population, continuous GGI entered the model [hazard ratio (H.R.) of 75th versus 25th = 2.79; P = 0.01], displacing luminal-A-like subtype; within HR+/HER2- (H.R. = 5.36; P < 0.001), GGI was the only remaining prognostic factor.In multivariate interaction analysis (including central and genomic grade), luminal-B-like subtype [HR+ and (Ki-67 ≥20% or HER2+)] was predictive for benefit of EC-Doc versus FEC in unselected but not in HR+/HER2- patients.

CONCLUSION

In the WSG-AGO EC-Doc trial for intermediate-risk BC, CG, intrinsic subtype (by IHC), and GG provide prognostic information. Continuous GGI (but not IHC4) adds prognostic information even when IHC subtype and CG are available. Finally, the high interobserver variability for histological grade and the still missing validation of Ki-67 preclude indicating or omitting adjuvant chemotherapy based on these single factors alone.

TRIAL REGISTRATION

The WSG-AGO/EC-Doc is registered at ClinicalTrials.gov, NCT02115204.

Reaktion und Reaktionsgleichgewicht beim Polyvinylalkohol-Cu˙˙-Muskel

Bei Zugabe von Cu˙˙-Salzen zu verdünnten wäßrigen Lösungen von Polyvinylalkohol bildet sich eine Komplexverbindung.

Die Bildung des Komplexes ist mit dem Auftreten eines Absorptionsmaximums bei λ = 2600 Å verbunden. Dies gestattet, die Gleichgewichtskonstante der Reaktion und insbesondere die pH-Abhängigkeit des Gleichgewichts durch Messung der Lichtabsorption mit Hilfe eines UV-Spektrometers festzustellen. Auf Grund der beobachteten pH-Abhängigkeit ergibt sich als Reaktionsgleichung die Beziehung

Dieser Reaktionsgleichung gemäß werden bei der Reaktion eines Cu˙˙ mit in Wasser gelöstem Polyvinylalkohol 2 Gruppen zu einer, ein gemeinsames Cu enthaltenden Gruppierung vereinigt, so daß zwei ursprünglich getrennte Gruppierungen - CH (OH) · CH2 · CH (OH) - miteinander valenzmäßig verbunden werden. In verdünnter Lösung von Polyvinylalkohol wird damit eine Ringbildung oder Selbstvernetzung einzelner Makromoleküle, in konzentrierter Lösung eine Fremdvernetzung unter Gelbildung, in einer gequollenen Polyvinylalkoholfolie eine Kontraktion der Folie durch Bildung zusätzlicher Vernetzungspunkte herbeigeführt. Die Selbstvernetzung in hoch verdünnter und die Fremdvernetzung in konzentrierter Polyvinylalkohollösung kann durch Messung der Viskositätsänderung festgestellt und (im Falle der hoch verdünnten Lösung) quantitativ interpretiert werden.

Die in einer anderen Arbeit festgestellte Tatsache, daß beim mechanischen Dehnen einer teilweise kontrahierten, mit dem Einbettungsmedium in Berührung stehenden Polyvinylalkoholfolie eine Abgabe von Cu˙˙ ans Einbettungsmedium, also eine Verschiebung des Komplexbildungsgleichgewichts, stattfindet (teinochemische Beziehung), wird in einfacher Weise verständlich gemacht. Sie ergibt sich aus dem Massenwirkungsgesetz und der experimentellen Tatsache einer Lösungsmittelaufnahme des Gels beim mechanischen Dehnen.

Impaired colour discrimination in Huntington's disease

Colour discrimination and visual contrast perception were investigated in 18 patients with Huntington's disease (HD) and in 18 age- and sex-matched healthy volunteers using the Farnsworth-Munsell 100 Hue test (FM) and stationary contrast targets. The mean total error score (MTES) and the partial scores for the "red-green" and the "blue-yellow" axes in the FM of the patients with HD were significantly elevated as compared to controls (MTES in HD: 113.0 ± 90.8; MTES in controls: 19.2 ± 8.8). The spatial contrast sensitivity in HD patients was normal. The colour perception dysfunction indicates that the visual system is affected in HD. The visual disorder may be related to an imbalance of certain neurotransmitters in the visual system of HD patients. Possible anatomical sites of the dysfunction responsible for colour discrimination abnormalities could be the retinal cone system and/or impaired parvocellular central visual pathways in HD.

Abstract S3-4: Ten year follow-up analysis of intense dose-dense adjuvant ETC (epirubicin (E), paclitaxel (T) and cyclophosphamide (C)) confirms superior DFS and OS benefit in comparison to conventional dosed chemotherapy in high-risk breast cancer patients with ≥ 4 positive lymph nodes

Background: The 5-year analysis of adjuvant chemotherapy with intense dose-dense (IDD) ETC had shown a significant improved DFS (HR 0.72; p &lt; 0.001) and OS (HR 0.76; p = 0.29) in comparison with conventional dosed chemotherapy (J Clin Oncol 28: 2874–2880, 2010). In contrast to other dose-dense trials the ETC regimen is dose-dense and dose-intensified. Long-term results are essential to evaluate the impact of dose-dense chemotherapy in the adjuvant treatment of breast cancer patients (pts). We now report the final analysis of DFS, OS, and long-term safety including the application of epoetin alfa after 10 years of follow-up.

Patients and Methods: A multi-center phase-III trial of the German AGO Breast Study Group recruited 1284 pts from 12/98 until 4/03. Pts below 65 years of age were eligible if at least 4 axillary lymph nodes were infiltrated. In the experimental arm, pts were assigned to receive three courses each of epirubicin (150 mg/m2), paclitaxel (225 mg/m2) and cyclophosphamide (2500 mg/m2) at 2-week intervals (q2w) (ETC) with G-CSF support (5µg/kg/SC day 3–10). In the standard arm 4 courses of conventional dosed epirubicin/cyclophosphamide (90/600 mg/m2) followed by 4 courses of paclitaxel (175 mg/m2) were given (EC→T). All cycles were administered in 3-week intervals without growth factor support. A second randomization ± epoetin alfa was performed in the IDD-ETC arm only (150IU/kg/sc three times weekly) to reduce the number of red blood cells (RBC's) transfusion and to evaluate the impact of epoetin alfa on DFS and OS in the adjuvant setting.

Results: 58% and 42% of the pts presented with 4–9 and ≥ 10 positive nodes with a median number of 8 involved nodes. The median age was 51 years and median follow-up was 122 months. We observed 604 DFS events (282 with IDD ETC; 322 with EC→T) (p = 0.00014, one-sided; HR 0.74; 95% CI, 0.63 to 0.87). IDD ETC improved DFS irrespective of nodal status, HER2 and ER status. 446 pts. have died (201 events in the IDD ETC arm vs. 245 events in the standard arm). 10 year OS rates were 69% with IDD ETC and 59% with EC→ T (p = 0.0007; two-sided; HR, 0.72; 95% CI, 0.60–0.87). Nine cases of acute myeloid leukemia or myelodysplastic syndrome occurred in the IDD ETC arm vs. two cases in the standard arm. 28% of pts in the IDD ETC arm vs. 13% in the IDD ETC arm plus epoetin alfa (p &lt; 0.0001) received RBC's transfusions. There was no difference between the IDD ETC arm alone and the IDD ETC + epoetin alfa arm regarding 10-year DFS and OS ((57% vs. 55% (p = 0.69) and 70% vs. 68% (p = 0.45)).

Conclusion: Intense dose-dense ETC remains significantly superior compared to standard chemotherapy after 10 years of follow-up. The risk of secondary leukemia/MDS in the IDD ETC arm (1.3% of pts) is comparable to that of the Cancadian CEF regimen. The prevention of RBC's transfusions and anemia by the application of epoetin alfa in the IDD ETC-arm had no impact on DFS and OS. IDD ETC is a highly effective and safe regimen in the adjuvant treatment of high-risk breast cancer pts.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr S3-4.

Association of serum autoantibodies to tumor-suppressor gene p53 in patients with ovarian cancer according to status of the disease

Sera from 130 ovarian cancer patients and from 118 normal control volunteers were assayed for serum autoantibodies to p53 using an enzyme-linked immunosorbent assay (ELISA). Overall, autoantibodies were detected in 41% of ovarian cancer patients as compared to 0.9% of healthy individuals (P<0.001). The incidence of autoantibodies was lower in patients with complete remission (20%) as compared to those with recurrence (48%, P<0.01) and before primary surgery (49%, P<0.05). There was no statistically significant correlation between p53 serum autoantibody status and tumor stage, degree of malignancy and histological subtype. Comparing the autoantibody status with p53 antigen expression in the corresponding tissue resulted in 57% consistent results. Thus, serological testing for p53 autoantibodies provides additional information and may be associated with the disease status in patients with ovarian cancer.

Synthesis of polymer-derived ceramic Si(B)CN-carbon nanotube composite by microwave-induced interfacial polarization

We demonstrate synthesis of a polymer-derived ceramic (PDC)-multiwall carbon nanotube (MWCNT) composite using microwave irradiation at 2.45 GHz. The process takes about 10 min of microwave irradiation for the polymer-to-ceramic conversion. The successful conversion of polymer coated carbon nanotubes to ceramic composite is chemically ascertained by Fourier transform-infrared and X-ray photoelectron spectroscopy and physically by thermogravimetric analysis and transmission electron microscopy characterization. Frequency dependent dielectric measurements in the S-Band (300 MHz to 3 GHz) were studied to quantify the extent of microwave-CNT interaction and the degree of selective heating available at the MWCNT-polymer interface. Experimentally obtained return loss of the incident microwaves in the specimen explains the reason for heat generation. The temperature-dependent permittivity of polar molecules further strengthens the argument of internal heat generation.

P1-06-03: Predictive Value of HER2, Topoisomerase-II (Topo-II) and Tissue Inhibitor of Metalloproteinases (TIMP-1) for Efficacy of Taxane-Based Chemotherapy in Intermediate Risk Breast Cancer – Results from the EC-Doc Trial

Background: Despite extensive research, there is still no consensus on optimal predictors for use of taxane-based chemotherapy (cht) in early breast cancer. Some studies have revealed HER2 as a significant predictive marker for efficacy of taxanes and anthracyclines. TIMP-1 and Topo-II are reported to be predictive for anthracycline efficacy. In our previous reports, both Ki-67≥20% and central G3 status emerged as significant predictors for taxane benefit. We have now compared HER2 and Topo-II (as protein expression and gene amplification) and TIMP-1 immunoreactivity as well as factor combinations (HT (HER2/TIMP-1) and 2T (Topo-II/TIMP-1) regarding their predictive value for benefit from taxane-based cht.

Methods: The EC-Doc trial randomized 1950 patients with 1–3 positive LN to 6x CEF/CMF vs. 4xEC-4xDoc. Significantly better DFS and OS favoring EC-Doc have been previously reported (Nitz et al., SABCS 2008). Protein expression and gene amplification data as well central histology/grade were available for 772 patients. Survival analysis was performed using Cox proportional hazards and Kaplan-Meier statistics. Analysis of HER2 survival impact status was prospectively planned.

Results: The entire and the investigated study populations did not differ regarding baseline characteristics. After median follow up of 64 months, both DFS (5y 90% vs. 80%, p=0.006) and OS (5y 95% vs. 92%, p=0.022) rates significantly favored EC-Doc vs. CEF in this cohort as well. HER2 over-expression (3+ and/or FISH≥2.0) was reported in 158 tumors (20%), Topo-II aberration (deletion or amplification) was reported in 78 (49.4%) HER2+ and in 83 (13.6%) HER2−negative tumors; 496 tumors were classified as TIMP-1 immunoreactive (65.2%). None of these factors were significantly prognostic for EFS in this collective. Regarding DFS, EC-Doc was strongly superior to FEC in HER2+ tumors (HR=0.29, 95%CI: 0.12−0.7, p=0.006) but not in HER2− tumors (p=0.18). In Topo-II aberrated tumors, the benefit of EC-Doc was remarkably strong (HR=0.28, 95% CI: 0.11−0.69, p=0.006), whereas the benefit was not significant in Topo-II normal tumors (p=0.16), which comprise more than ¾ of the total. In contrast, Topo-II protein overexpression (&gt;10%) was not associated with a stronger benefit in either subgroup. The superiority of EC-Doc to FEC was significant in the larger group of TIMP-1 immunoreactive tumors (HR=0.57, p=0.025) but not in TIMP-1 negative tumors (p=0.14), similar behavior was seen in “HT” and “2T” subgroups (significance with HR about 0.5 in the “+” subgroups). In a multivariate model for DFS including age, tumor size, Ki-67, central grade, HR, HER2, TOPO_II aberration, TIMP-1 status, therapy and interactions of all these factors with therapy arm, the only significant therapy interaction was that of (high) Ki-67 (HR=0.76, 95% CI: 0.59−0.98, p=0.03); significant main effects in this model were age, central grade, and Ki-67.

Conclusions: These data suggest predictive significance for Topo-II aberration, TIMP immunoreactivity and HER2 over-expression as well as a multivariate predictive significance of high Ki-67 for enhanced benefit of taxane-based cht.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-06-03.

Abstract P2-09-14: Evidence for Predictive and Prognostic Impact of Molecular Classification in Taxane-Based Chemotherapy in Intermediate Risk Breast Cancer — An Analysis of the WSG EC-Doc Trial

Background: Patients with hormone receptor positive breast cancer (BC) and 1-3 positive lymph nodes (LN) belong to the intermediate risk-group. Among these patients chemoendocrine therapy may be considered. The prognostic role of molecular breast cancer subgroups and their predictive impact regarding taxane-and anthracycline based chemotherapy is unclear. This analysis evaluated the ability of molecular subtypes to predict outcome after standard FEC or EC-Doc chemotherapy in pts with 1-3 positive LN.

Methods: The EC-Doc trial randomized 2012 patients with 1-3 positive LN to 6x FEC/CMF vs. 4x EC followed by 4 x docetaxel (Doc). Significantly better DFS and OS in favor of EC-Doc was reported previously (Nitz et al., SABCS 2008). Protein expression data and central histology/grade (G) were available for 772 patients (Control n=390; EC-Doc n=382). Protein expression was measured on tissue micro arrays for ER, PR, Her2 (both IHC/FISH), Ki-67, Ck 5/6, and EGFR. Molecular subgroups were classified using ki-67 cutt-off of 13.25 % (Cheang et al. JNCI 2009). Results: There was no difference in baseline characteristics (age, LN, grade, tumor size, HR) between the entire ITT-study population and the investigated cohort of 772 pts. There were significantly more G 3 tumors in the basal and Her2 group and more G 1/2 tumors in the luminal A cohort. Distribution of molecular subtypes is as follows:

- Luminal A: HR+ (ER and/or PR+), low KI-67 and Her2-: 26.1%

- Luminal B: HR+ and either Ki-67 high or Her2+: 44.8%

- Her2: HR-and Her2+: 10.9%

- Triple negative (TN) basal-like ER/PR/Her2- ; Ck 5/6+ and/or EGFR+: 11.8%

- TN non-basal-like: TNBC; both Ck 5/6 and EGFR-: 6.4%

After median follow up of 64 months, both DFS (5y 90% vs. 80%, p=0.006) and OS (5y 95% vs. 92%, p=0.022) rates also significantly favored EC-Doc vs. FEC in this cohort. DFS rates were highest in luminal A and lowest in TN basal-like tumors.

In univariate analysis a significant benefit of EC-DOC vs. FEC for DFS is seen in luminal B patients (p=0.004; HR=0.41; (0.22-0.77)). EC-Doc was also better than FEC in HR-patients who were not “basal-like (p=.057; HR=0.385 (0.14 — 1.07).

In multivariate analysis including age, nodal status, tumor size, molecular subtypes, and chemotherapy regimen age, luminal A subtype, and interaction of EC-Doc and luminal B subtype (HR=0.44) influenced significantly DFS survival. Conclusions: These data provide evidence that molecular subtypes are associated with both different levels of benefit from EC-Doc and different DFS within each treatment group. These retrospective results will be validated within the prospective WSG PlanB trial.

Table/Figure 1: multivariate model for DFS

Tabid Parameters bssdciated with benefitfrctm EC-Dgccompared to CEF in a multivariate tnofiel tor DFS

Abstract P2-02-03: Influence of Pre-Operative MRI on the Eligibility for Accelerated Partial Breast Irradiation (APBI)

Purpose: Accelerated partial breast irradiation (APBI) following breast-conserving therapy is currently under investigation in prospective randomized studies. Multifocality and multicentricity are exclusion criteria for APBI. It is proven that pre-operative breast MRI has the ability to dectect ipsilateral and contralateral invasive tumor foci or DCIS in addition to conventional diagnostic methods (clinical examination, mammography and ultrasonography). The objective of this retrospective study was to evaluate the impact of pre-operative MRI on the patient selection for APBI. Patients and methods: From 2002 until 2007 a total of 579 consecutive, non-selected patients with newly-diagnosed early-stage breast cancer received pre-operative Breast MRI in addition to conventional imaging studies at the Bonn University Breast Cancer Center. In total, 130 patients met the criteria for APBI by conventional imaging studies (pathologic tumor size ≥3 cm, negative axillary node status, unifocal disease, no evidence of distant metastases, no invasive lobular carcinoma, lobular carcinoma in situ or Paget's disease). We analyzed the amount of additional ipsi-and contralateral tumor foci detected by MRI.

Results: MRI detected additional tumor foci in 7,6 % of patients eligible for APBI (11 tumor foci in 10 out of 130 patients), either ipsilateral (n=7/5,4%) or contralateral (n=4/3.1 %). In one patient MRI found an additional tumor focus both ipsi-and contralateral. Conclusions: Pre-operative breast MRI may be useful for patient selection for APBI. Its ability to identify additional tumor foci in a clinically relevant number of cases may help to avoid undertreatment of these patients.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-02-03.

Prognostic Significance of Molecular Subtypes in Male Breast Cancer

INTRODUCTIONThe relatively unfavorable outcome in male breast cancer has been attributed to more advanced local tumor stage and high incidence of lymph node invasion at the time of diagnosis. This study aimed to classify the molecular subtypes of male breast cancers based on the expression profile of immunomarkers and to evaluate their association with clinicopathological features and patients outcome.METHODSTo define molecular subtypes a total of 174 cases of male breast carcinoma were examined retrospectively using immunostains for hormone receptors (HR) and cytokeratin 5/6 (CK5/6). Human epidermal growth factor receptor 2 (HER2) expression was evaluated by immunostaining and confirmed by fluorescent in situ hybridization. Tumor characteristics and overall survival (OS) data were available and correlated with protein expression and the molecular subtype.RESULTSThe luminal A subtype (HR+/HER2-) was the most common subtype in male breast cancer (82.8%; n=144) with a median patients OS of 122 month. Luminal B tumors (HR-/HER+) were found in 6.2% (n=11), basal-like (HR-/HER2-/CK5/6+) in 9.6% (n=17) and HER2+/HR- carcinomas in 1.1% (n=2). Basal like male breast carcinoma showed a statistically significant reduced overall survival (median: 51 month; p&lt;0.01). Due to the low number of patients prognostic significance of HER2 positivity (luminal B and HER2+/HR-subtype) was not evaluable.CONCLUSIONSIn our study group, luminal A was the predominant subtype of male breast carcinoma and showed an excellent patients outcome. However, like in females tumors with a basal like subtype which were known to show minor chemotherapy response had a worse prognostic outcome. Therefore, new therapeutic options have to be defined.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2110.