Node-negative Primary Breast Cancer Research Articles

Association Between Neutrophil-Lymphocyte Ratio and Oncotype Dx Recurrence Score in Early-Stage Hormonal Receptor-Positive, HER2-Negative, Node-Negative Breast Cancer.

PurposeThe correlation between the preoperative neutrophil-to-lymphocyte ratio (NLR) and Oncotype DX® (ODX) recurrence score (RS) has not yet been established. We aimed to investigate the association between NLR and ODX RS in patients with hormone receptor-positive (HR+) and human epidermal growth factor receptor 2-negative (HER2−) early-stage breast cancer (BC).Patients and MethodsThis retrospective study included consecutive patients with HR+/HER2−, node-negative primary BC who underwent surgical tumor resection from 2011 to 2019. Receiver operating characteristic curve analysis was used to obtain an optimal NLR cutoff value. Logistic regression analyses were used to estimate associations between various parameters and ODX RS. Furthermore, the factors significantly associated with the ODX RS in multivariable analysis were incorporated in a separate model and estimated using logistic regression.ResultsA total of 160 patients were enrolled. The optimal preoperative NLR cutoff was 2.15. Multivariable analysis revealed that NLR and tumor grade (G1/G2 vs G3) were independent predictive factors of high RS cutoff (≥26). Moreover, including the two variables yielded a stronger association; patients with low NLR and low-grade tumors were unlikely to have high RS (≥26; odds ratio [OR] = 0.03, 95% confidence interval [CI]: 0.006–0.154; p < 0.001). Conversely, the presence of any of the following factors made patients unlikely to have low RS (<16; OR = 0.34, 95% CI: 0.16–0.73; p = 0.006): high NLR, high grade, or high Ki-67 levels (>20).ConclusionNLR is a promising independent predictor of RS. Furthermore, in addition to tumor grade and Ki-67 level, they together are also a potential indicator of high and low RS. However, further studies are required to validate this hypothesis.

High CYP27A1 expression is a biomarker of favorable prognosis in premenopausal patients with estrogen receptor positive primary breast cancer

27-hydroxycholesterol (27HC), synthesized from cholesterol by the enzyme CYP27A1, differentially impacts estrogen receptor positive (ER+) breast cancer (BC) cell growth depending on estrogen levels. This study examined the association between CYP27A1 expression and prognosis in a cohort of 193 premenopausal patients with lymph node-negative primary BC with limited exposure to adjuvant systemic cancer treatments. In multivariable analyses among patients with ER+ tumors, high CYP27A1 protein and mRNA expressions were associated with four- and eight-fold reductions in the incidence of distant recurrence-free survival events: HRadj = 0.26, 95% CI = 0.07–0.93 and HRadj = 0.13, 95% CI = 0.03–0.60, respectively. In vitro studies revealed that 27HC treatment potently inhibited ER+ BC cell proliferation under lipid-depleted conditions regardless of estradiol levels, transcriptionally mediated through the downregulation of ER signaling with a concomitant upregulation of cholesterol export. Importantly, if validated, these results may have implications for adjuvant treatment decisions in premenopausal patients, especially when de-escalation of therapy is being considered.

Prognosis of Patients With Early Breast Cancer Receiving 5 Years vs 2 Years of Adjuvant Bisphosphonate Treatment

Bisphosphonate treatment in patients with early breast cancer has become part of care, but the optimal treatment duration is still unclear. To compare 2 vs 5 years of zoledronate treatment following adjuvant chemotherapy in patients with early breast cancer. The SUCCESS A phase 3 multicenter randomized open-label clinical trial with a 2 × 2 factorial design enrolled 3754 patients from September 21, 2005, to March 12, 2007 (last patient out, May 7, 2014). Final data analysis was conducted from September 2019 to October 2020. In 250 German study centers, patients were eligible for participation in the SUCCESS A trial if they had either node-positive or high-risk node-negative (defined as at least 1 of the following: tumor size ≥ pT2, histologic grade 3, negative hormone receptor status, or age ≤35 years) primary invasive breast cancer. Patients were first randomized to adjuvant chemotherapy with 3 cycles of fluorouracil, epirubicin, and cyclophosphamide followed by 3 cycles of docetaxel with or without gemcitabine (not presented in this report). After chemotherapy, patients underwent a second randomization of 5 years of zoledronate treatment (4 mg intravenously every 3 months for 2 years, followed by 4 mg intravenously every 6 months for 3 years) vs 2 years of zoledronate treatment (4 mg intravenously every 3 months for 2 years). The primary end point of the study was disease-free survival; secondary end points were overall survival, distant disease-free survival, and the incidence of skeletal-related adverse events. Survival times were measured from 2 years after the start of zoledronate treatment (landmark analysis). Overall, data on 2987 patients were available for analysis; median age was 53 (range, 21-86) years. Disease-free survival, overall survival, and distant disease-free survival did not differ significantly between the 2 treatment arms (5 vs 2 years) as shown by adjusted multivariable Cox proportional hazards regression models (disease-free survival: hazard ratio [HR], 0.97; 95% CI, 0.75-1.25; P = .81; overall survival: HR, 0.98; 95% CI, 0.67-1.42; P = .90; distant disease-free survival: HR, 0.87; 95% CI, 0.65-1.18; P = .38). Adverse events were observed more often in the 5-year (46.2%) vs 2-year (27.2%) zoledronate treatment arm, which was particularly true for the skeletal-related events bone pain (5 years, 8.3% vs 2 years, 3.7%) and arthralgia (5 years, 5.1% vs 2 years, 3.1%). The results of this phase 3 randomized clinical trial indicate that extending the zoledronate treatment beyond 2 years does not improve the prognosis of high-risk patients with early breast cancer receiving chemotherapy, suggesting that the currently recommended bisphosphonate treatment duration of 3 to 5 years could be reduced. ClinicalTrials.gov Identifier: NCT02181101.

Abstract PD2-07: Real-time navigation for sentinel lymph node biopsy in breast cancer patients using projection mapping with indocyanine green fluorescence

Abstract Background) Sentinel lymph node (SLN) biopsy using indocyanine green fluorescence (fICG) method showed equal or better identification rate compared with blue dye or radioisotope (RI) method. In the fICG method, lymphatic vessels which drain into the SLNs can be seen through skin or subcutaneous tissue using near infrared camera (Photodynamic Eye®: PDE), and we can easily find the SLNs. However, whenever we observe the fluorescence images, we have to hold the PDE, turn off the operating light, and look at a monitor because fluorescence images cannot be seen directly. Medical imaging projection system (MIPS) is a new device which detects fluorescent emission from the organ and projects their images on the location of the fluorescence emission (Panasonic Connected Solutions Company, Japan). Projected images can be adjusted following the body movement or deformation of the organ. Therefore, MIPS could provide an option for real-time navigation for the SLN biopsy. The aim of this study was to evaluate the clinical utility of the MIPS. Patients and methods) Patients with clinically node-negative primary breast cancer underwent the fICG SLN biopsy using MIPS. Primary endpoint was identification rate of the fICG method using MIPS. At first, the study was conducted as an interventional study because the MIPS was the unapproved medical device. After approval of the MIPS, this study was conducted as an observational study. The study protocol was approved by the institutional review board at Kyoto University Hospital. All patients provided informed consent to participate in this study. Results) Between March 2016 and May 2017, 39 patients (40 procedures) underwent the fICG method SLN biopsy using MIPS. The median age was 55 years (range 32–74 years), and the median body mass index was 20.4 kg/m2 (range 17.7–27.7 kg/m2). About half had tumor stage T1 (58%) and 8 (20.0%) had DCIS. 8 procedures (20%) were performed after preoperative systemic therapy (PST). As MIPS itself can illuminate the operating field, SLN biopsy using MIPS was successfully performed without operating light in all procedures. At least one SLN was detected using MIPS for all procedures and the identification rate was 100% (95% CI: 91–100%). Median number of SLNs detected by MIPS was 3 (range 1–9) for all procedures, and 3 (range 2–8) for procedures after PST. Two pathologically positive SLNs and one SLN which included isolated tumor cells were detected by MIPS. In 25 procedures, RI was also used. 62 of 97 SLNs detected by MIPS (64%) were also detected by RI. However, no SLNs were detected only by RI. Conclusions) Although we still may not be able to avoid RI method because 25/40 (62.5%) procedures required the combined use of RI method, the fICG methods SLN biopsy using MIPS, which showed comparable identification rate of SLN with the conventional methods, could be useful tool with a view of allowing us to perform a real-time navigation surgery. Acknowledgements) This study was supported by Acceleration Transformative research for Medical innovation, Japan Agency for Medical Research and Development (AMED). Citation Format: Takada M, Takeuchi M, Suzuki E, Sato F, Matsumoto Y, Torii M, Sakita-Kawaguchi N, Nakayama Y, Okuda T, Nishino H, Seo S, Hatano E, Toi M. Real-time navigation for sentinel lymph node biopsy in breast cancer patients using projection mapping with indocyanine green fluorescence [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD2-07.

Risk of mortality of node-negative, ER/PR/HER2 breast cancer subtypes in T1, T2, and T3 tumors.

The purpose of this study was to assess differences in breast cancer-specific mortality within tumors of the same size when breast cancer was defined using the three tumor markers estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). We identified 104,499 cases of node-negative primary female invasive breast cancer from the California Cancer Registry. Tumor size was categorized as T1a, T1b, T1c, T2, and T3. Breast cancer was defined using ER, PR, and HER2. Kaplan-Meier Survival analysis was conducted and Cox Regression was used to compute the adjusted risk of mortality for the ER+/PR+/HER2+, ER-/PR-/HER2-(TNBC), and ER-/PR-/HER2+ (HER2-overexpressing) subtypes when compared with the ER+/PR+/HER2-. Separate models were computed for each tumor size. Unadjusted survival analysis showed that for all tumor sizes, the ER+/PR+ subtypes regardless of HER status have better breast cancer-specific survival than ER-/PR- subtypes. Subtype was not an important factor for risk of mortality for T1a tumors. The ER+/PR+/HER2+ subtype was only a risk for mortality in T1b tumors that were unadjusted for treatment. For all other tumor sizes, the ER+/PR+/HER2+ had the same mortality as the ER+/PR+/HER2- subtype regardless of adjustment for treatment. The HER2-overexpressing subtype had a higher risk of mortality than the ER+/PR+/HER2- subtype except for T1b tumors that were adjusted for treatment. For all tumor sizes, the TNBC had higher hazard ratios than all other subtypes. T1a tumors have the same risk of mortality regardless of ER/PR/HER2 subtype, and ER and PR negativity plays a stronger role in survival than HER2 positivity for tumors of all size.

Abstract P2-01-07: Reoperative sentinel lymph node biopsy for ipsilateral breast tumor recurrence: Impact of axillary surgery and radiation therapy on lymphatic drainage patterns

Abstract Background: While sentinel lymph node biopsy (SLNB) is a well-established method for patients with clinically node-negative primary breast cancer, reoperative sentinel lymph node biopsy (re-SLNB) for ipsilateral breast tumor recurrence (IBTR) still remains controversial. The aim of this study was to evaluate the location of reoperative sentinel lymph nodes (re-SLNs) and the factors related to aberrant drainage patterns after breast conserving surgery (BCS). Methods: Between April 2005 and August 2013, we performed re-SLNB on 132 patients who developed IBTR with no metastatic lymph nodes in preoperative examination. Both injection of radioisotope (Tc-99m phytate) and preoperative lymphoscintigraphy were performed on 97 patients of them, who were eligible for this retrospective study. We divided these patients into two groups according to their previous axillary surgery: 55 patients with just SLNB or no axillary surgery to the group S, and 42 patients with previous axillary lymph node dissection (ALND) to the group D. The patients in the group S were divided into two subgroups: 19 with adjuvant radiation therapy (RT) and 36 without RT. We compared visualization rates of lymph drainage patterns in these groups statistically by using Chi-square test. We evaluated the relationship between previous local treatments and lymphatic drainage patterns. Results: Number of cases in which lymphatic drainage was visualized were 52 (94.5%) in the group S and 33 (78.6%) in the group D (P &amp;lt; 0.001). Re-SLNs were observed at ipsilateral axilla in 47 patients (90%) in the group S and 19 patients (58%) in the group D (P &amp;lt; 0.001), at internal mammary (IM) in 9 (17%) and 16(49%) (P &amp;lt; 0.01), and at contralateral axilla in 8 (15%) and 5(15%), respectively. Within the group S, lymphatic drainage was visualized in 34 (94.4%) of 36 patients without RT and 18 (94.7%) of 19 patients who had received RT after BCS. Re-SLNs were visualized at ipsilateral axilla in 34 (100%) and 13 (72%) (P &amp;lt; 0.01), at IM in 5 (15%) and 4 (22%), and at contralateral axilla in 1 (3%) and 7 (39%) (P &amp;lt; 0.001). Re-SLNB was successfully performed in 62 (94%) of 66 patients whose lymphatic drainage was observed at ipsilateral axilla. Metastases for carcinoma in re-SLNs were found in 8 (13%) of them. At IM, re-SLNB was successful in 15 (60%) of 25, and 2 (13%) of them were positive for cancer. At contralateral axilla, re-SLNB was successful in 8 (62%) of 13 while no metastases were found among them. Conclusion: Previous ALND affected the visualization rates of re-SLNs. In patients after previous ALND, SLN was more likely to be in IM. Adjuvant RT effected a change in lymphatic drainage patterns, but did not affect the visualization rate of re-SLN. At ipsilateral axilla, the rates of successful re-SLNB and metastases at re-SLNs were similar to SLNB for primary breast cancer. Metastasis to SLN of recurrent cancer is one of the most important information for management of IBTR. However, it was very difficult to predict localization of re-SLN because lymphatic drainage patterns could have been affected by previous treatments. Therefore, we recommend re-SLNB using radioisotope with lymphoscintigraphy in surgery for IBTR. Citation Format: Ayaka Sato, Takehiko Sakai, Fumiko Moroo, Kiyomi Kimura, Masahiko Tanabe, Rie Horii, Futoshi Akiyama, Takuji Iwase. Reoperative sentinel lymph node biopsy for ipsilateral breast tumor recurrence: Impact of axillary surgery and radiation therapy on lymphatic drainage patterns [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 P2-01-07.

Population based study on sentinel node biopsy before or after neoadjuvant chemotherapy in clinically node negative breast cancer patients: Identification rate and influence on axillary treatment

The timing of the sentinel lymph node biopsy (SNB) is controversial in clinically node negative patients receiving neoadjuvant chemotherapy (NAC). We studied variation in the timing of axillary staging in breast cancer patients who received NAC and the subsequent axillary treatment in The Netherlands.Patients diagnosed with clinically node negative primary breast cancer between 1st January 2010 and 30th June 2013 who received NAC and SNB were selected from the Netherlands Cancer Registry. Data on patient and tumour characteristics, axillary staging and treatment were analysed. Two groups were defined: (1) patients with SNB before NAC (N=980) and (2) patients with SNB after NAC (N=203).Eighty-three percent of patients underwent SNB before NAC, with large regional variation (35–99%). The SN identification rate differed for SNBs conducted before and after NAC (98% versus 95%; p=0.032). A lower proportion of patients had a negative SNB when assessed before NAC compared to after (54% versus 67%; p=0.001). The proportion of patients receiving any axillary treatment was higher for those with SNB before NAC than after (45% versus 33%; p=0.006).In conclusion, variation exists in the timing of SNB in clinical practice in The Netherlands for clinically node negative breast cancer patients receiving NAC. The post-NAC SN procedure is, despite some lower SN identification rate, associated with a significantly less frequent axillary treatment and thus with less expected morbidity. The effect on recurrence rate is not yet clear. Patients in this registry will be followed prospectively for long-term outcome.

A 39-gene signature is associated with early occurrence of distant metastasis in primary lymph-node negative breast cancers.

Risk factors of the development of distant metastasis in primary node-negative breast cancer patients are heterogeneous. Identification of patients at high risk of early distant metastasis is of important clinical significance. In the current study, using the already published datasets, we develop agene signature that can robustly predict early distant metastasis for patients with primary node-negative breast cancer. We identified a39-gene signature, which were associated with distant metastasis and shorter distant metastasis free survival (DMFS) in node-negative breast cancers. Using the survival prediction analysis method in BRB-Array tools, this signature can stratify patients into early- and late- distant metastasis subgroups with different DMFS in VDX training dataset (AUC=0.734, P< 0.01). And we further validated the reliability of the prognostic value of this 39-gene signature in another two independent breast cancer cohorts (NKI dataset, AUC=0.642, P<0.0167; TRANSBIG dataset, AUC=0.711, P<0.0167). Furthermore, the early distant metastasis subgroups defined by the 39-gene signature exhibited asignificant association with ER negative status and more aggressive molecular subtypes in all three datasets, and with poor differentiation status in two datasets. In summary, we developed anovel distant metastasis-related gene signature for predicting early occurrence of distant metastasis in node-negative breast cancers, what might be useful in making treatment decisions for these early metastasis patients.

Persistence of HER2 overexpression on circulating tumor cells in patients after systemic treatment for HER2-positive breast cancer: Follow-up results of the German Success B trial.

11043 Background: The discordance between HER2-expression on circulating tumor cells (CTC) in peripheral blood and the primary tumor has already been shown by our study group for early breast cancer patients with HER2-positive tumors. Here, we compare the results to CTC prevalence and HER2-status of CTC after adjuvant chemotherapy. Methods: The SUCCESS B trial compares FEC-Docetaxel vs. FEC-Docetaxel-Gemcitabine and HER2-targeted therapy as adjuvant treatment for patients with early, HER2-positive, node positive or high risk node negative primary breast cancer. We prospectively analyzed 23ml peripheral blood before and after chemotherapy. CTC and HER2-status were assessed with the CellSearchSystem (Veridex, USA). After immunomagnetic enrichment with an anti-Epcam-antibody, cells were labeled with anti-CK 8/18/19, anti-CD45 antibodies as well as a fluorescein conjugate antibody for HER2-phenotyping. Cutoff for CTC positivity was ≥ 1 CTC. HER-positivity of CTC was assigned if at least one CTC showed strong HER2 staining (3+). Results: CTCs and their HER2-status both before and after chemotherapy were available for 392 patients. In 179 (45.7%) patients no CTC were detected before and after chemotherapy. CTC status changed from positive before to negative after chemotherapy in 104 (26.5%) patients and from negative before to positive after chemotherapy in 69 (17.6%) patients, while 40 (10.2%) patients had a consistently positive CTC status. Patients were significantly more likely to change their CTC status from positive to negative than from negative to positive (p = 0.01). Of the 40 patients with CTC both before and after chemotherapy, 14 (35%) patients had HER2-positive CTC before and after therapy, and 9 (22%) patients had HER2-negative CTC at both time points. 7 (18%) patients had HER2-positive CTC before but not after chemotherapy, while 10 (25%) patients showed the reverse pattern (p = 0.63). Conclusions: Cytotoxic treatment does not seem to influence the HER2-status on CTC. Follow-up data within the Success B trial will analyze the relevance of the HER2-expression of CTC to predict the efficacy of targeted treatment.

Health economic impact of risk group selection according to ASCO-recommended biomarkers uPA/PAI-1 in node-negative primary breast cancer

Invasion factors uPA/PAI-1 are guideline-recommended (ASCO, AGO) biomarkers for decision support regarding adjuvant chemotherapy (CTX) in women with primary breast cancer. They define a high-risk group with strong benefit from adjuvant CTX and a low-risk group with uncertain benefit and excellent survival without CTX. In a target population (age > 35/N0/G2/HR+/HER2-), administration of adjuvant CTX is not mandatory in Germany and other countries. Based on existing data, this economic model was developed to determine for the first time health economic impact of uPA/PAI-1 testing. Incremental cost-effectiveness ratio (ICER) resulting from uPA/PAI-1 testing was estimated for the target population by Markov modeling and sensitivity analysis. Survival data, CTX-uPA/PAI-1 interactions, and uPA/PAI-1 hazard ratios were derived from the Chemo N0 trial and other evidence. Incremental costs were computed from a payer's perspective appropriate to the German setting. Incremental effectiveness in life years (ly) was estimated taking into account age-adjusted life expectancy, disease-free survival (with/without CTX), and 2 years post-relapse survival. Sensitivity analysis was performed by varying residual adjuvant CTX benefit in the low-risk group, denoted HR_CTX(LR), in range 0.8-0.99. All patients receive adjuvant endocrine therapy. Test is restricted to patients willing to forgo CTX if both markers are below specific cut-off values and to undergo CTX otherwise. For a typical 55-year-old patient, comparing to an "all-CTX" strategy without the test, ICER (all-CTX vs. test) > <euro>50,000 if HR_CTX(LR) > 0.85, with savings of <euro>18,500 per low-risk patient attributable to the test. The cost-effectiveness of forgoing CTX is very high as HR_CTX(LR) approaches one. Conversely, comparing to a "no-CTX" strategy (e.g., patients who initially refuse CTX) without the test, the test is very cost-effective at all ages in the target group if high-risk patients are willing to undergo CTX: ICER (test vs. no-CTX) < <euro>6,000 at age 55 and even better at younger ages, remaining < <euro>25,000 up to age 75. The main determinants of cost utility are age and residual CTX benefit in low-uPA/PAI-1 patients. The uPA/PAI-1 test is cost-effective in the target group compared to either an "all-CTX" or a "no-CTX" scenario. This model thus lends health economic support to current guideline recommendations that uPA/PAI-1 testing is beneficial for BC patients with no lymph node involvement.

Abstract P2-01-02: Circulating Tumor Cells (CTC) may Express HER2/neu in Patients With Early HER2/neu Negative Breast Cancer – Results of the German SUCCESS C Trial

Abstract Background: There is growing evidence that the HER2/neu-status of distant metastases or minimal residual disease in blood and bone marrow may differ from the primary tumor in patients with breast cancer. The HER2/neu-status of CTCs was prospectively evaluated in patients with HER2/neu negative primary breast cancer randomized into the German multicenter SUCCESS C study. Methods: The SUCCESS C trial is a randomized Phase III study comparing FEC-Docetaxel (FEC-Doc) vs. Docetaxel-Cyclophosphamid (DC) as well as 2 years of a lifestyle-intervention in patients with early, HER2/neu negative, node positive or high-risk node negative primary breast cancer. As part of the translational research program, 23ml peripheral blood were drawn after adjuvant chemotherapy. In 505 samples, the prevalence of CTCs and their HER2/neu-status were assessed using the CellSearch System (Veridex, USA). After immunomagnetic enrichment with an anti-Epcam-antibody, cells were labelled with anti-CK8/18/19 and anti-CD45 antibodies. A fluorescein conjugate antibody with anti-CK-Fluorescein Isothiocyanate (FITC) was used for HER2/neu phenotyping. The cut-off for CTC-positivity was ≥ 1 CTC and for HER2/neu ≥ 1 CTC with strong HER2/neu-staining (+++). Results: 26,9% of pts (n = 136) were positive for CTCs (mean 1.78; range 1–7; median = 1). The number of detected CTC was distributed as follows: 1 CTC (n = 76; 55.9%), 2 CTCs (n = 35; 25.7%), 3 CTCs (n = 13; 9.6%), 4 CTCs (n = 7; 5.2%) and ≥ 5 CTCs (n = 5; 3.7%). HER2/neu staning of CTCs was not detectable or weak in 26.5% (n = 36) and 4.4% (n = 6) of CTC positive patients respectively and therefore categorized as HER2/neu negative. In 32.4% of the CTC-positive patients (n = 44), we detected moderate and in 36.8% (n = 50) strong HER2/neu-staining of ≥ 1 CTC per sample. No association was found between CTCs or the HER2/neu-status of CTCs with tumor size, histopathological grading, hormone receptor status or axillary lymph node involvement. Conclusions: The data of this trial confirm previous findings that patients with HER2/neu negative primary breast cancer can show HER2/neu positive minimal residual disease. These results underline the importance of frequent HER2/neu determination during follow up and disease progression. Survival data within the Success C trial will give further insight into the tumor biology of HER2/neu negative disease. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-01-02.

Current Controversies in Breast Cancer Surgery

Contemporary management of the axilla in breast cancer surgery remains in evolution. Axillary lymph node status in breast cancer is a major prognostic factor and remains integral to guiding adjuvant treatment decisions. There remains controversy regarding the management of the node-positive axilla in clinically node-negative primary breast cancer. Trials to date have suggested re-evaluation of the historical therapeutic strategy that a positive sentinel node requires axillary node dissection. However, further evidence is required before modern clinical management of the axilla should be altered. As patient awareness and technical expertise grow, national rates of breast reconstruction after mastectomy continue to rise. Oncoplastic techniques continue to evolve and many patients are suitable for a plethora of reconstructive options. Despite the widespread practice of breast reconstruction globally, there is limited randomised evidence comparing the optimal type and/or timing of breast reconstruction on which to base practice. Breast reconstruction type is either purely autologous, implant-based or a combination of these two techniques. We explore the benefits and limitations of these techniques and some of the key findings of the National Mastectomy and Breast Reconstruction Audit. The timing of reconstruction after mastectomy is either immediate (a single procedure) or delayed (for an indefinite period after mastectomy). The ideal reconstruction is one that is best aligned to the patient's expectations, as this will achieve the highest levels of long-term patient satisfaction. Selecting the optimal type of breast reconstruction at the right time for the right patient remains the key challenge in breast reconstruction.

Influence of the number of removed axillary lymph nodes on the prognosis of node-negative primary breast cancer

To analyze the relationship between the number of removed axillary lymph nodes and prognosis of axillary node-negative breast cancer. The clinicopathological data of 655 patients with breast cancer were analyzed retrospectively. The disease-free survival curves were generated according to the number of removed axillary lymph nodes using Kaplan-Meier plots. The correlation between the co-variables and rate of breast cancer-related events was analyzed using Cox model. The overall five year-disease free survival rate of the 655 cases was 94.4%. The rate of patients with lymph node number ≤ 12 was 90.3%, and that of lymph node number > 12 was 96.5%, with a statistically significant difference (P = 0.009). Significantly less breast cancer-related events were observed in patients with lymph node number > 12 (15/426, 3.5%) than that in patients with lymph node number ≤ 12 (22/229, 9.6%) (P = 0.009). When axillary node dissection is indicated, dissection of lymph nodes >12 leads to much less breast cancer-related events than that in patients with dissected lymph node ≤ 12. The more lymph nodes are dissected, the more accurate prognosis can be estimated.

Diagnosis of axillar lymph node status and sentinel node biopy (SNB) by indocyanin green (ICG) fluorescence imaging in early breast cancer patients.

e11503 Background: In breast cancer patients, diagnosis of Axillar lymph node (Ax LN) status is practical use in deciding treatment strategy. But, diagnostic methods are different by different institution. The purpose of this study was to review diagnostic methods of Ax LN status. Methods: From December 2006, 483 cases were underwent breast cancer operation and within 356 (74%) clinical node negative primary breast cancer cases underwent Sentinel Node biopsy (SNB) by indocyanine green (ICG) fluorescence imaging. Dye was injected sub dermal in the areola. After one minute massage, subcutaneous lymphatic channel draining from the areola to the axilla was observed by Image processing and measuring system (PDE C9830, Hamamatsu Photonics Co). Skin incision was done at the point which fluorescence imaging disappeared (ASCO2011, Electronic Publication only). From September 2010, Aspiration Biopsy Cytology (ABC) of Ax LN (LN-ABC), Ultrasonography (US) and CT were done as routine workup in breast cancer patients. Node positive cases were received pre-operative chemotherapy or Ax LN dissection and node negative cases were underwent SNB by ICG fluorescence imaging during operation. Results: From December 2006, SNB were done 356 clinical node negative primary breast cancer cases. SN was detected 342 cases, detective rate was 96 %. This rate was as good as SNB done by radioactive colloid (Phytate radiolabelled by Tc98) with dye (detective rate was 95%, ASCO2011). The lymph node metastasis was detected 48 cases (14%). From Sep 2010 to Oct 2011, LN-ABC was done 49 cases of the 142 primary breast cancer patients. Fourteen cases were LN-ABC positive and 35cases were LN-ABC negative. Positive SNB were detected 3 of the 35 cases (2 cases had micro metastasis and one case had macro metastasis). Within three SNB positive cases, pre-operative US and CT had no positive finding. Positive LN-ABC cases (14 cases) were received pre-operative therapy or Ax LN dissection. Conclusions: These results suggest that LN-ABC was useful procedure detecting positive Ax LN and SNB by ICG fluorescence imaging was useful and easy tool in operative breast cancer patients.

Chemotherapy-induced amenorrhea in premenopausal breast cancer patients treated with adjuvant anthracycline and taxane based chemotherapy within the SUCCESS study.

554 Background: Chemotherapy induced amenorrhea (CIA) is often used as a surrogate marker for cytotoxic gonadal damage. The aim of this analysis was to identify predicitve factors for CIA in premenopausal breast cancer patients treated with adjuvant chemotherapy. Methods: The German multicenter, phase III SUCCESS trial compared 3 cycles of FEC q3w followed by 3x docetaxel q3w vs. FEC followed by Doc+gemcitabine as adjuvant treatment in patients with node positive or high risk node negative primary breast cancer. Premenopausal patients with hormone receptor positive tumors underwent endocrine treatment with tamoxifen (Tam) for 5 years. Additional goserelin (GnRH) for 2 years was given in the following cases: Age &lt;40 years at study entry, premenopausal hormone status or regular menses within 6 months after chemotherapy. We retrospectively investigated CIA rates of 1.189 initially premenopausal patients during disease-free follow-up. Results: Median age at diagnosis was 44 years (range 21-50). The median follow up time was 44 months (range 1-62). 791 patients (66.5%) received endocrine treatment. Tam intake was reported in 370 patients, GnRH in 29 patients, Tam+GnRH in 392 patients. In 963 patients (81.0%) CIA occurred for ≥3 months after chemotherapy. In 22.7% of initially amenorrheic patients CIA was temporary. 192 patients (16.2%) had continuous menstrual bleeding. In multivariate analysis the risk of CIA was significantly higher in older patients, increasing by factor 1.32 per life year (p&lt;0.0001). Tam intake was also associated with increased CIA rates (p=0.0032). Patients with combined Tam+GnRH were more likely to resume menses compared to patients without endocrine therapy (p=0.0056). Factors like the cytotoxic regimen, tumor stage, grading, the patient`s BMI or the use of GnRH analogues as ovarian protectants during chemotherapy did not correlate with CIA rates. Conclusions: Age was the strongest predictor for CIA. Tam administered alone increased CIA rates. Opposite effects were observed for patients who received Tam+GnRH. The addition of gemcitabine to sequential anthracyline-taxane based chemotherapy did not influence CIA.

Correlation of BMI with tumor stage in early breast cancer patients (pts): Pooled analysis of the German SUCCESS A, B, and C trials.

1602 Background: Independent from known prognostic factors, e.g., tumor size and nodal status, obesity is a risk factor for poor disease free, distant disease free, and overall survival in breast cancer. The aim of this analysis was to examine the correlation of the body mass index (BMI) with tumor characteristics in early breast cancer. Methods: We analyzed the data of 7,997 pts with early, node positive or high risk node negative primary breast cancer treated with adjuvant taxan-based chemotherapy within the German multicenter phase III SUCCESS A, B, or C trials. The pts’ tumor stage at primary diagnosis was classified according to the UICC tumor-node-metastasis (TNM) classification. Additionally, the tumor’s hormone-receptor status and HER2/neu status were determined. Before enrollment into the study each patient was grouped according to the WHO global database on BMI. Contingency table methods were used to analyze the correlation of BMI and tumor characteristics. Results: Among the 7,997 pts 100 (1.3%) pts were underweight, 3,556 (44.5%) pts were normal weight, 2,569 (32.1%) pts were overweight and 1,772 (22.2%) were obese. Of all pts 4,508 pts (56.4%) suffered from a pT2-4 tumor, 4830 (60.4%) showed lymph node involvement (pN1-3) and 7509 (93.9%) had G2-3 tumors. 5839 pts (73.0%) showed positivity for ER or PR and 935 (11.7%) for HER2/neu. Overweight and obese pts had significantly larger tumors compared to pts with normal BMI (p&lt;0.0001; p&lt;0.0001). Furthermore, overweight and obesity were associated with a significantly higher rate of lymph node involvement (p=0.0001; p=0.0003) respectively. In contrast neither grading, tumor histology, ER/PR-status nor HER2/neu-overexpression were correlated with BMI. Conclusions: These data are the first to show in a large number of pts that both obese and overweight women suffering from primary breast cancer have significantly larger tumors and more often positive axillary lymph nodes. As there are no differences in tumor biology, the advanced tumor stage might be due to more difficult and delayed detection of breast cancer and lymph node lesions in these women.

HER2 expression on circulating tumor cells (CTC) in patients with early HER2-positive breast cancer: Results of the German SUCCESS B trial.

10540 Background: Recent reports showed a discrepancy in the Her2-status of metastases or minimal residual disease in blood and bone marrow compared to the primary tumor in patients with breast cancer. The Her2-status of CTC was prospectively evaluated in the German multicenter SUCCESS B study. Methods: The SUCCESS B trial is a randomized Phase III study comparing FEC-Docetaxel (Doc) vs. FEC-Docetaxel-Gemcitabine (Doc-G) as well as Her2 targeted therapy with Trastuzumab as adjuvant treatment in patients with early, Her2 positive, node positive or high risk node negative primary breast cancer. As part of the translational research program, 23ml of peripheral blood were drawn before adjuvant chemotherapy. In 638 samples CTC and Her2-status were assessed using the CellSearch System (Veridex, USA). After immunomagnetic enrichment with an anti-Epcam-antibody, cells were labeled with anti-CK8/18/19, anti-CD45 antibodies as well as a fluorescein conjugate antibody for Her2 phenotyping. Cutoff for CTC-positivity was ≥1 CTC and for Her2 ≥1 CTC with strong Her2-staining (+++). Results: 40.2% of pts (n=257) were positive for CTC (mean 4.52; range 0-1689). The number of detected CTC was distributed as follows: 1 CTC (n=112; 43.6%), 2 CTC (n=65; 25.3%), 3 CTC (n=36; 14.0%), 4 CTC (n=12; 4.7%) and ≥5 CTC (n=31; 12.1%). Her2 status on CTC was negative or weak in 12.5% (n=32) and 8.9% (n=23) of CTC positive patients respectively and therefore categorized as Her2 negative. In 21.4% (n=55) we detected moderate and in 57.2% (n=147) strong Her2-staining of ≥1 CTC per sample. Therefore 57.2% of CTC-positive samples were diagnosed as Her2 positive and 21.4% as questionable. No association was found between the detection of CTC or the Her2-status on CTC with tumor size, histopathological grading, hormone receptor status or axillary lymph node involvement. Conclusions: The data of this trial confirms the frequent discordance of Her2 expression on CTC compared to the primary tumor. Survival data within the Success B trial will give further insight into the tumor biology of Her2 positive disease and the role of the Her2-status on CTC to predict treatment efficacy.

35P Adjuvant Chemotherapy in Node-Negative (N0) Breast Cancer: Routine Upa/Pai-1 Determination

ABSTRACT More than 70% of patients with primary node-negative breast cancer are treated with local therapy alone. Biomarkers are used to determine disease risk and, consequently, determine whether or not chemotherapy is needed. Urokinase plaminogen activator (uPA) and its inhibitor plasminogen activator inhibitor 1 (PAI-1) are proteases implicated in invasiveness of tumor. The clinical utility of these markers has been proven on the highest level of evidence (LOE-1) in node-negative breast cancer patients. They are ASCO–recommended cancer biomarkers since 2007 and French Cancer Society (INCA)-recommended since 2009. But clinical routine use is poorly developed. The purpose was to register adjuvant chemotherapy decisions by a multidisciplinary discussion using uPA/PAI-1 concentrations compared to conventional prognostic parameters. The study was performed between January 2010 and December 2011. It included 164 frozen breast cancer tissue for determination of uPA and PAI-1 levels by enzyme-linked immunosorbent assay (ELISA) at Marseille Laboratory. However, the assay required a fresh-frozen tissue sample, which was not always feasible (25% of cases) because of tumor size or technical problems. UPA concentration of ≤3 ng/mg total protein and PAI-1 concentration of ≤14 ng/mg total protein were classified as low risk and one elevated marker classified patient as high risk. Tissues were always excised more than 10 days post breast biopsy and were frozen in a delay of 30 to 60 min. Results were obtained in 10 days post excision. Parameters were prospectively registered: age, menopausal status, tumor size, histological grade, steroid hormone receptor, Her2 overexpression, KI67, vascular embolism. Sixty-six tumors were uPA/PAI-1 negative, 41 uPA + /PAI-1 + , 12 uPA + /PAI-1- and 45 uPA-/PAI-1+. In the first 120 patients, uPA/PAI-1 value was discordant with conventional parameters, with a lower or higher prognostic index in 13 and 40 cases respectively. In some cases, the multidisciplinary decisions do not follow this score because of patient age, HER2 overexpression, grade 1 and limit level of uPA/PAI-1. Clinical decisions will be discussed and clinical routine problems of treatment with implication of the patients explained. Disclosure All authors have declared no conflicts of interest.

P5-14-05: Anti-Müllerian Hormone (AMH) Levels in Premenopausal Breast Cancer Patients Treated with Adjuvant Chemotherapy – A Translational Research Project of the SUCCESS Study.

Abstract Background: Premenopausal women undergoing chemotherapy are at risk of premature ovarian failure and long term side-effects caused by premature menopause. However, knowledge about the rate of ovarian failure and potential markers to evaluate the ovarian reserve is limited, especially in the context of modern chemotherapy concepts. Therefore, Anti-Müllerian hormone (AMH) was measured at before, immediately after and 2 years after chemotherapy in premenopausal patients of the SUCCESS study. Materials and Methods: The German SUCCESS trial is a multicenter phase III study comparing FEC-Docetaxel vs. FEC-Docetaxel+Gemcitabine as adjuvant treatment in patients with node positive or high risk node negative primary breast cancer. Blood samples were taken prior to and 4 weeks after last cycle of adjuvant chemotherapy, as well as after 2 years of follow up. We retrospecitvely identified 170 patients stratified premenopausal and aged 40 years or younger at trial entry, who received 3cycles of FEC (500/100/500mg/m2) q3w followed by 3 cycles of docetaxel (100mg/m2) q3w as one of the most commonly used chemotherapy regimens in Europe. Serum AMH levels were evaluated in a central laboratory by a manual immunoassay AMH DSL ELISA (Diagnostic Systems Laboratories, Webster, USA). Results: Median age within this subgroup was 36 years (21-40 years). 48% of the patients had a tumor stage pT1 and 54% were node positive. 69% were hormone receptor positive and 29% Her2 positive. Median serum AMH level before adjuvant chemotherapy was 1.32 ng/ml (range &amp;lt;0.1−11.32). Immediately after chemotherapy AMH levels dropped in 96% of the patients below the threshold of detection (&amp;lt;0.1 ng/ml, range &amp;lt;0.1−3.9ng/ml). No association to classical prognostic markers, such as tumor stage, lymph node involvement, etc. was observed. After a follow up period of 2 years, serum was available from 95 patients. 76% of those patients showed no evidence of ovarian function indicated by AMH (&amp;lt;0.1 ng/ml, range &amp;lt;0.1−1.43ng/ml). AMH levels prior to and 2 years after chemotherapy were significantly correlated with older age, with a reduction of 0.14 ng/ml per life year (p=0.0025) and 0.01 ng/ml (p=0.017) respectively. 12 patients (7%) received optional gonadotropin-releasing hormone (GnRH) agonists during chemotherapy. These patients presented significantly higher AMH levels (+ 0.18 ng/ml; p=0.01) 2 years after cytotoxic treatment. Conclusion: In this retrospective analysis premenopausal patients showed a high rate of ***f ovarian insufficiency reflected by low serum AMH levels immediately after cytotoxic treatment and after 2 years of follow up. GnRH agonists given as ovarian protectants during chemotherapy may have an influence on serum AMH 2 years after chemotherapy. Further data from prospective trials with longer follow up are needed to evaluate the role of serum AMH as a predictor of ovarian failure in breast cancer patients exposed to chemotherapy. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-14-05.

P1-06-06: The Importance of CXCL10 and CXCR3-A in Breast Cancer.

Abstract Background: CXCL10 is a chemokine with chemo attractant properties which signals through G protein-coupled receptor CXCR3. At least two reported isoforms exists; CXCR3-A and CXCR3-B. CXCL10 is involved in the recruitment of leucocytes, immune modulation and angiogenesis. In animal models CXCL10 inhibits tumour growth, metastase formation and inhibits angiogenesis. The receptors have opposite features; CXCR3-A mediates proliferative or anti-apoptotic response and CXCR3-B mediates growth inhibition and apoptosis in response to ligand binding. The aim of this study was to investigate the role of CXCL10 and CXCR3-A as prognostic or tamoxifen treatment predictive factors in breast cancer. Material and Methods: A randomized tamoxifen trial comprising 1,780 breast cancer patients was conducted in Stockholm, Sweden, 1976–1990. All patients had lymph node negative primary breast cancer and were postmenopausal at the time of diagnosis. The patients were randomized to tamoxifen or no endocrine treatment. We analyzed the protein expression of CXCL10 and the receptor CXCR3A with immunohistochemistry using tissue microarrays, which were constructed from paraffin blocks originating from 912 patients. CXCL10 and CXCR3A could be scored in 793 (87%) and 735 (81%), respectively. Results: High expression of CXCL10 was associated with significant benefit of tamoxifen treatment concerning local recurrence and breast cancer survival (P=0.02 and P=0.008). For patients with high CXCL10 expression, tamoxifen decreased the risk concerning local recurrence (rate ratio (RR) = 0.56, 95% C.I. 0.33−0.97, P=0.0029) and breast cancer survival (RR 0.6 95% C.I. 0.39−0.97, P=0.023). High expression of CXCR3-A was associated with significant benefit of tamoxifen treatment concerning total recurrence and breast cancer survival (P=0.00001 and P=0.004, respectively). For patients with high CXCR3-A expression, tamoxifen decreased the risk of total recurrence (RR 0.54 95% C.I. 0.35−0.83, P=0.005) and breast cancer survival (RR 0.49 95% C.I. 0.35−0.69, P=0.00003). On the opposite, in the cohort of patients with no endocrine treatment and high CXCR3-A expression, there was an increased risk of total recurrence (P=0.003). (RR 2.07 95% C.I. 1.18−3.61, P=0.011). Conclusions: This study indicates that high expression of CXCL10 can be used as predictive markers for tamoxifen treatment. Further, high expression of CXCR3-A is related to bad prognosis and predicts tamoxifen treatment in breast cancer patients. This needs to be further evaluated. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-06-06.