Node-positive Tumors Research Articles

Current Practice Patterns in Locally Advanced Rectal Cancer at Academic Institutions: A National Survey Among Radiation Oncologists, Medical Oncologists, and Colorectal Surgeons

PurposeTo assess the current treatment patterns in locally advanced rectal cancer (LARC) among radiation oncologists (RO), medical oncologists (MO), and colorectal surgeons (SR) specializing in gastrointestinal (GI) malignancies at academic institutions. Materials and MethodsAn online survey consisting of 7 LARC clinical vignettes was distributed to GI specialists practicing at ACGME accredited academic institutions. Treatment paradigms consisted of long-course chemoradiation (LC-CRT) and short-course (SCRT) radiotherapy, chemotherapy (CHT), and surgery. The survey was open from January to April 2021. ResultsThirty-six RO, 14 MO and 21 SR (71/508 physicians) replied resulting in a response rate of 14.0%. For low rectal node positive tumors, 88.7% of primary recommendations incorporated TNT (73.1% LC-CRT, 26.9% SCRT). NOM was preferred by 41.3% if a clinical complete response (cCR) was achieved. The presence of high-risk features led 95.8% of physicians to employ TNT (79.4% LC-CRT, 20.6% SCRT). For a cT3N1-2 mid-rectal tumor without high-risk features, 85.9% would primarily recommend TNT (56.6% LC-CRT, 43.4% SCRT). For a cT4bN2a mid-rectal tumor without high-risk features, 97.2% of primary recommendations included TNT (76.9% LC-CRT, 23.1% SCRT). ConclusionAmong academic RO, MO, and SR, the traditional regimen of LC-CRT, surgery, and adjuvant CHT is now infrequently recommended for LARC. TNT has been widely adopted for locally advanced node positive rectal tumors with variable patterns of care with respect to sequencing of CHT and RT. Fractionation with LC-CRT remained the majority. Non-operative management after a cCR in low rectal tumors has gained traction transforming LARC from a once classically perceived surgical disease.

Clustering Molecular Subtypes in Breast Cancer, Immunohistochemical Parameters and Risk of Axillary Nodal Involvement.

(1) Background: To establish similarities in the risk of axillary lymph node metastasis between different groups of women with breast cancer according to immunohistochemical (IHC) parameters. (2) Methods: Data was collected retrospectively, from 2000 to 2013, of 1058 node-positive breast tumours. All patients were divided according to the St Gallen 2013 criteria and IHC features. The proportion of axillary involvement (pN > pN0; pN > pN1mi; pN > pN1) was calculated for each group. Similarities in axillary nodal dissemination were explored by cluster analysis and association between IHC and risk of axillary disease was studied with multivariate analysis. (3) Results: Among clinico-pathological surrogates of intrinsic subtypes, axillary involvement was more frequent in Luminal-B like HER2 negative (45.8%) and less frequent in Luminal-B HER2 positive (33.8%; p = 0.044). Axillary macroscopic involvement was more frequent in Luminal-B like HER2 negative (37.9%) and HER2 positive (37.8%) and less frequent in Luminal-B HER2 positive (25.5%) and Luminal-A like (25.6%; p = 0.002). Axillary involvement ≥pN2 was significantly less frequent in Luminal-A like (7.4%; p < 0.001). Luminal-A with Luminal-B HER2 positive, and triple-negative with Erb-B2 overexpressing tumours were clustered together regarding any axillary involvement, macroscopic disease or ≥pN2. Among the defined subgroups, axillary metastases were more frequent when Ki67 was higher. In a multivariate analysis, Ki67>14% were associated with a risk of axillary metastases (HR: 1.31; 95% CI, 1.51–6.80; p < 0.037). (4) Conclusions: there are two lymphatic drainage pathways of the breast according to the expression of hormone receptor-related genes. Positive-ER tumors are associated with lower axillary involvement and negative-ER tumors and Ki67 > 14% with higher nodal involvement.

Recurrent Disease After Esophageal Cancer Surgery: A Substudy of The Dutch Nationwide Ivory Study.

This study investigated the patterns, predictors, and survival of recurrent disease following esophageal cancer surgery. Survival of recurrent esophageal cancer is usually poor, with limited prospects of remission. This nationwide cohort study included patients with distal esophageal and gastroesophageal junction adenocarcinoma and squamous cell carcinoma after curatively intended esophagectomy in 2007 to 2016 (follow-up until January 2020). Patients with distant metastases detected during surgery were excluded. Univariable and multivariable logistic regression were used to identify predictors of recurrent disease. Multivariable Cox regression was used to determine the association of recurrence site and treatment intent with postrecurrence survival. Among 4626 patients, 45.1% developed recurrent disease a median of 11 months postoperative, of whom most had solely distant metastases (59.8%). Disease recurrences were most frequently hepatic (26.2%) or pulmonary (25.1%). Factors significantly associated with disease recurrence included young age (≤65y), male sex, adenocarcinoma, open surgery, transthoracic esophagectomy, nonradical resection, higher T-stage, and tumor positive lymph nodes. Overall, median postrecurrence survival was 4 months [95% confidence interval (95% CI): 3.6-4.4]. After curatively intended recurrence treatment, median survival was 20 months (95% CI: 16.4-23.7). Survival was more favorable after locoregional compared with distant recurrence (hazard ratio: 0.74, 95% CI: 0.65-0.84). This study provides important prognostic information assisting in the surveillance and counseling of patients after curatively intended esophageal cancer surgery. Nearly half the patients developed recurrent disease, with limited prospects of survival. The risk of recurrence was higher in patients with a higher tumor stage, nonradical resection and positive lymph node harvest.

EE194 Cost-Effectiveness Analysis of the Oncotype DX Breast Recurrence Score® Test for Postmenopausal Women with HR+/HER2- Node-Positive Early Breast Cancer in Canada

The Oncotype DX Breast Recurrence Score® test identifies patients with HR+/HER2- early breast cancer who are most likely to benefit from adjuvant chemotherapy and reports a Recurrence Score® (RS) result. Based on the RxPONDER study, postmenopausal women with node-positive tumours (N1, 1-3 axillary lymph modes) and RS results 0-25 can be safely spared chemotherapy. An economic evaluation using a decision model was conducted to estimate the cost-effectiveness of the Oncotype DX® test compared to clinical risk alone from a healthcare cost perspective in Ontario, Canada in HR+/HER2- node-positive early breast cancer.

The role of postoperative radiation therapy in stage I–III male breast cancer: A population-based study from the surveillance, epidemiology, and End Results database

BackgroundThis study aimed to investigate the role of postoperative radiation therapy in a large population-based cohort of patients with stage I–III male breast cancer (MaBC). MethodsPatients with stage I–III breast cancer treated with surgery were selected from the Surveillance, Epidemiology, and End Results cancer database from 2010 to 2015. Multivariate logistic regression identified the predictors of radiation therapy administration. Multivariate Cox regression model was used to evaluate the predictors of survival. ResultsWe identified 1321 patients. Age, stage, positive regional nodes, surgical procedure, and HER2 status were strong predictors of radiation therapy administration. There was no difference between patients who received radiation therapy and those who did not (P = 0.46); however, after propensity score matching, it was associated with improved OS (P = 0.04). In the multivariate analysis of the unmatched cohort, the factors associated with better OS were administration of radiation therapy and chemotherapy. In the subset analysis of the unmatched cohort, postoperative radiation therapy was associated with improved OS in men undergoing breast-conserving surgery (BCS), with four or more node-positive or larger primary tumours (T3/T4). Furthermore, we found no benefit of radiation therapy, regardless of the type of axillary surgery in mastectomy (MS). In older MaBC patients with T1-2N1 who underwent MS, radiation therapy showed no significant effects, regardless of chemotherapy. ConclusionPostoperative radiation therapy could improve the survival of MaBC patients undergoing BCS, with four or more node-positive or larger primary tumours. Moreover, it should be carefully considered in patients undergoing MS and older T1-2N1 patients.

Evaluation of the Hybrid Tracer Indocyanine Green- 99m Tc-Nanocolloid for Sentinel Node Biopsy in Bladder Cancer-A Prospective Pilot Study.

RationaleIn muscle-invasive bladder cancer (MIBC), lymph node invasion has proven to be an independent predictor of disease recurrence and cancer-specific survival. We evaluated the feasibility of targeting the sentinel node (SN) for biopsy in MIBC patients using the hybrid tracer indocyanine green (ICG)–99mTc-nanocolloid for simultaneous radioguidance and fluorescence guidance.MethodsTwenty histologically confirmed cN0M0 MIBC patients (mean age, 63.3 years; range, 30–82 years), scheduled for radical cystectomy with SN biopsy and extended pelvic lymph node dissection (ePLND), were prospectively included. Twelve patients were operated on following neoadjuvant chemotherapy. The patients received lymphoscintigraphy as well as SPECT/CT after 4 transurethral injections of ICG-99mTc-nanocolloid (mean, 208 MBq; range, 172–229 MBq) around the tumor/scar in the detrusor muscle of the bladder on the day before radical cystectomy. Sentinel node resection was performed under radioguidance and fluorescence guidance.ResultsNineteen patients could be analyzed. On preoperative imaging, SNs could be identified in 10 patients (53%; mean, 1.6 SN/patient), which revealed drainage pathways outside the ePLND in 20% of the patients. Interesting to note is that 2 patients (10%) with preoperative nonvisualization displayed fluorescent and radioactive SNs during surgery. Location of the primary tumor near the left lateral side of the bladder seemed to be a factor for nonvisualization. Nodal harvesting with ePLND varied among patients (mean, 23.3). Histopathology confirmed tumor-positive nodes in 4 (21%) of all patients. In the 2 patients where an SN could be identified, the ePLND specimens were tumor-negative. All patients with tumor-positive nodes had advanced disease (stage III).ConclusionSentinel node biopsy in bladder cancer using the hybrid tracer ICG-99mTc-nanocolloid is feasible, and preoperative imaging is predictive for the ability to perform SN biopsy in 83% of the patients who displayed an SN. In patients with a successful preoperative SN mapping using lymphoscintigraphy and SPECT/CT, the intraoperative SN guidance and detection were effective, even outside the ePLND area. As such, this study underscores the critical role that preoperative imaging plays in challenging image-guided surgery applications.

SO-10 The prognostic role of microarchitecture in tumour-positive lymph nodes in oesophageal cancer patients: Results from the UK MRC OE02 trial

Patients with resectable oesophageal cancer (OeC) have a 25-47% 5-year overall survival (OS). The strongest prognostic factor is pathological lymph node (LN) status. Regional tumour-draining LNs play an important role in the host anti-tumour immune response. We previously demonstrated that the microarchitecture in tumour-negative LNs (LNneg) changes after chemotherapy and predicts OS. It is currently unknown whether neoadjuvant chemotherapy induces microarchitectural changes in regional tumour-positive LNs (LNpos) which might impact patient's OS. We hypothesized that (1) LNpos in OeC patients treated with chemotherapy and surgery contain fewer germinal centres compared to patients treated by surgery alone and (2) that patients with an activated anti-tumour immune response (e.g. more germinal centres and more lymphocytes) in the regional LNpos have a better OS. Digitized haematoxylin/eosin-stained sections of 129 OE02 trial patients with at least one LNpos were analyzed (70 treated with surgery alone (S patients), 59 treated with chemotherapy and surgery (CS patients)). The area of the different histological components (lymphocytes, germinal centres, histiocytes, tumour tissue) of the largest LNpos per patient was manually quantified by point counting as surrogate of LNpos microarchitecture. The %area of individual immune features in the tumour-free LN area and %area of tumour were calculated. The relationship between individual histological LN components, largest LNpos diameter, treatment and clinicopathological variables was analyzed. Kaplan Meier method was applied for univariate OS from time of surgery and Cox proportional hazard model for multivariate survival analysis including (y)pT status in the model. There was no difference in LNpos microarchitecture between treatment arms. Combined analysis showed that tumour tissue occupied (median(range)) 8.9% of the largest LNpos area (0.01-44.4%). Lymphocytes occupied most of the tumour-free LNpos area (median (range) 65.2% LN area (2.1%-87.7%), followed by histiocytes (9.7% LN area (0%-59.3%)) and germinal centres (1.8% LN area (0%-16.9%)). No relationship between individual LNpos components and clinicopathological parameters was found. S patients with a high %area of histiocytes in the LNpos had a poorer survival in univariate (p=0.008; HR 1.05 95% CI (1.01-1.09)) and in multivariate analysis (p=0.04; HR 1.06 (1.02-1.09)). CS patients with a larger area of tumour in the LNpos showed decreased OS in univariate (p=0.04; HR 2.27 (1.29-3.99)) and in multivariate analysis (p=0.01; HR 2.11 (1.19-3.75). No other relationships with survival were seen. This is the first study to quantify LNpos microarchitecture on haematoxylin/eosin-stained sections and show that LNpos microarchitecture is similar between oesophageal cancer patients treated with chemotherapy and surgery or surgery alone. This might indicate that chemotherapy does not alter the quantitative immune response in tumour-positive lymph nodes of oesophageal cancer patients. Nevertheless, there are differences in prognostic value of histiocytes in tumour-positive lymph nodes in surgery alone patients and residual tumor burden in tumour-positive lymph nodes in chemotherapy patients. The underlying molecular mechanisms of these novel findings warrant further investigations by for example detailed immune-cell phenotyping within lymph nodes and matched primary tumour. Our results need to be confirmed in a second independent series to translate findings into post-surgery patient treatment decisions in the future.

Neo-adjuvant T-VEC plus nivolumab combination therapy for resectable early-stage or metastatic (IIIB-IVM1a) melanoma with injectable disease: The NIVEC trial.

TPS9607 Background: The prognosis of patients with melanoma is significantly correlated with disease stage and has greatly improved with the introduction of the currently approved therapies. Trials investigating neo-adjuvant treatment with immune checkpoint inhibitors (ICI) have shown high pathologic response rates up to 25-80%, however, still a large group of patients derive no (durable) clinical benefit. Treatment with talimogene laherparepvec (T-VEC), a modified herpes simplex virus type-1, is approved for patients with unresectable stage IIIB-IVM1a melanoma, with high and durable response rates and a mild toxicity profile. Earlier trials have suggested that T-VEC has the capacity to heighten the immune response and to elicit an abscopal effect in melanoma when given in combination with ICI. Combination ICI and intralesional T-VEC has already been investigated in patients with unresectable stage IIIB-IV disease, however, no data is available yet on the potential benefit of this combination therapy in neo-adjuvant setting. This is the first trial investigating the efficacy and safety of neo-adjuvant treatment of T-VEC in combination with nivolumab (anti-PD-1 antibody), followed by surgical resection in patients with resectable stage IIIB-IVM1a melanoma, with the potential of high pathologic response rates and acceptable toxicity. Methods: In this single center, single arm, phase II study, a total of 24 patients ≥18 years of age and a good clinical performance score with treatment naïve, stage IIIB-IVM1a melanoma (AJCC 8th edition) with injectable disease and resectable (sub)cutaneous satellite or in-transit metastases and/or tumor positive lymph nodes, will be included. Patients will receive four courses of T-VEC up to 4mL (first dose as seroconversion dose) and three doses of nivolumab (240mg flatdose) every two weeks, followed by surgical resection in week nine. The primary endpoint of this trial is pathologic response rate, with the aim to show a high major pathologic (near-complete or complete) response rate up to 45%. Secondary endpoints are safety according to CTCAE v5.0, the rate of delay of surgery and event free survival. Additionally, prognostic and predictive biomarker research and health-related quality of life evaluation will be performed. Enrollment started in June 2020 in the Netherlands Cancer Institute, with currently 13 of the 24 planned patients treated. Clinical trial information: NCT04330430.

Patterns of Recurrence After Robot-Assisted Minimally Invasive Esophagectomy in Esophageal Squamous Cell Carcinoma

Robot-assisted minimally invasive esophagectomy (RAMIE) has been proven to be a feasible surgical approach for esophageal squamous cell carcinoma (ESCC). This study aimed to investigate the recurrence pattern and potential risk factors after RAMIE. Consecutive patients with ESCC who received RAMIE with McKeown technique at a single Esophageal Cancer Institute from November 2015 to September 2018 were retrospectively reviewed. Patients with available data, radical resection (R0), and a minimum 2-year follow-up period were eligible for the recurrence analysis. Risk factors of recurrence were examined by logistic regression analysis. R0 resection was achieved in 95.1% of patients (310/326). Of the 298 eligible patients with a median follow-up period of 30.6 months, recurrence was recognized in 95 patients (31.9%), with 4 (1.3%) local-only, 40 (13.4%) regional-only, 44 (14.8%) hematogenous-only and 7 (2.3%) combined recurrences. Cervical lymph nodes and lungs were the most frequent sites of regional and hematogenous recurrence, respectively. The median disease-free interval until recurrence was 12.1 (range 1.7-37.6) months and 83.2% of relapses occurred within 2 years after surgery. Multivariable analysis indicated that tumor in the upper esophagus, larger tumor length and positive lymph nodes as independent risk factors for recurrence. Hematogenous recurrence is the prevailing pattern after RAMIE for ESCC. For patients with advanced disease, neoadjuvant therapy is a key factor in reducing recurrence rather than surgical approaches.

DNA methylation of miR-138 regulates cell proliferation and EMT in cervical cancer by targeting EZH2

BackgroundEmerging evidence has identified miR-138 as a tumor suppressor that can suppress the proliferation of various cancers. Meanwhile, the cause of abnormal miR-138 expression in cervical cancer remains uncertain. This study clarified the mechanism by which miR-138 regulates proliferation, invasion, metastasis, and EMT in cervical cancer cells.ResultsmiR-138 expression in human cervical cancer and adjacent normal tissue was measured using qPCR. SiHa and C33A cells were used to determine the function of miR-138 via miR-138 mimic or inhibitor transfection, followed by wound healing, Cell Counting Kit-8, flow cytometry, and Transwell assays. Epithelial and mesenchymal marker expression was analyzed using Western blotting. DNA methylation in the miR-138 promoter was examined using bisulfite sequencing PCR. The downstream target genes of miR-138 were identified via bioinformatics analysis and luciferase reporter assays. A tumor xenograft model was employed to validate DNA methylation-induced miR-138 downregulation and tumor growth inhibition in cervical cancer in vivo. miR-138 levels were significantly lower in cervical cancer tissues than in adjacent control tissues. Furthermore, lower miR-138 expression and higher CpG methylation in the miR-138 promoter were identified in lymph node-positive metastatic cervical cancer tumors versus that in non-metastatic tumor tissues. Upon miR-138 overexpression, cell proliferation, metastasis, invasion, and EMT were suppressed. miR-138 agomir transfection and demethylating drug treatment significantly inhibited cervical tumor growth and EMT in tumor xenograft models. DNA methylation inhibited miR-138 transcription, and enhancer of zeste homolog 2 (EZH2) downregulation mediated the tumor suppressor function of miR-138 in cervical cancer.ConclusionWe demonstrated that miR-138 suppresses tumor progression by targeting EZH2 in cervical cancer and uncovered the role of DNA methylation in the miR-138 promoter in its downregulation. These findings demonstrated the potential of miR-138 to predict disease metastasis and/or function as a therapeutic target in cervical cancer.

Impact of microsatellite status in early-onset colonic cancer.

The molecular profile of early-onset colonic cancer is undefined. This study evaluated clinicopathological features and oncological outcomes of young patients with colonic cancer according to microsatellite status. Anonymized data from an international collaboration were analysed. Criteria for inclusion were patients younger than 50 years diagnosed with stage I-III colonic cancer that was surgically resected. Clinicopathological features, microsatellite status, and disease-specific outcomes were evaluated. A total of 650 patients fulfilled the criteria for inclusion. Microsatellite instability (MSI) was identified in 170 (26.2 per cent), whereas 480 had microsatellite-stable (MSS) tumours (relative risk of MSI 2.5 compared with older patients). MSI was associated with a family history of colorectal cancer and lesions in the proximal colon. The proportions with pathological node-positive disease (45.9 versus 45.6 per cent; P = 1.000) and tumour budding (20.3 versus 20.5 per cent; P = 1.000) were similar in the two groups. Patients with MSI tumours were more likely to have BRAF (22.5 versus 6.9 per cent; P < 0.001) and KRAS (40.0 versus 24.2 per cent; P = 0.006) mutations, and a hereditary cancer syndrome (30.0 versus 5.0 per cent; P < 0.001; relative risk 6). Five-year disease-free survival rates in the MSI group were 95.0, 92.0, and 80.0 per cent for patients with stage I, II, and III tumours, compared with 88.0, 88.0, and 65.0 per cent in the MSS group (P = 0.753, P = 0.487, and P = 0.105 respectively). Patients with early-onset colonic cancer have a high risk of MSI and defined genetic conditions. Those with MSI tumours have more adverse pathology (budding, KRAS/BRAF mutations, and nodal metastases) than older patients with MSI cancers.

Sentinel lymph node procedure in patients with recurrent vulvar squamous cell carcinoma: a\xa0proposed protocol for a multicentre observational study

BackgroundStandard groin treatment in recurrent vulvar cancer consists of uni- or bilateral inguinofemoral lymphadenectomy (IFL), whereas in the primary setting women with selected unifocal tumours will undergo a sentinel lymph node (SLN) procedure. The SLN procedure results in fewer short and long-term sequelae compared to IFL, but some concerns must first be considered. Lymph drainage of the vulvar region can be affected by a previous surgery, which might reduce the number of detectable SLN nodes (feasibility) but increase the chance of encountering aberrant lymph drainage patterns such as bilateral SLNs in lateral tumours or SLNs at unexpected locations. Therefore, the SLN procedure potentially carries a higher risk of groin recurrence if a tumour positive node is not retrieved, but may also improve outcomes for women with aberrant drainage patterns. Since the relative benefits and drawbacks of the SLN procedure are still unclear we will investigate the safety of the SLN procedure in women with a first recurrent vulvar cancer. In a simultaneously started registration study we prospectively gather information on women with a first recurrence of vulvar cancer ineligible for the SLN procedure.MethodIn this prospective multicentre observational study all women with a first recurrence of vulvar cancer will be asked to consent to the collection of information on their diagnostics, treatment and outcome, and to complete quality of life and lymph oedema questionnaires. Women with unifocal tumours smaller than 4 cm and unsuspicious groin nodes will be offered the SLN procedure, with follow-up every 3 months together with imaging at 6 and 12 months when the SLN is tumour negative. The primary outcome is groin recurrence within 2 years of initial surgery. A total of 150 women with negative SLNs will be required to demonstrate safety, a stopping rule will apply and an extensive statistical analysis has been designed.DiscussionShould the SLN procedure prove feasible and safe in recurrent vulvar cancer, it will be available for implementation in clinics worldwide. The inclusion of women ineligible for the SLN procedure in the current prospective study will help to bridge knowledge gaps and define future research questions.Trial registrationMedical Ethical Committee approval number NL70149.078.19 (trial protocol version 2.0, date March 2nd, 2020). Affiliation: Erasmus Medical Centre. Dutch trial register NL8467. Date of registration 19.03.2020.

Perineural Invasion in Pancreatic Ductal Adenocarcinoma (PDAC): A Saboteur of Curative Intended Therapies?

(1) Background: Perineural invasion (PNI) is a common characteristic of pancreatic ductal adenocarcinoma (PDAC) and is present in most resection margins. We hypothesized that curative pancreatic tumor resection with long-term survival could only be achieved in PNI-negative patients. (2) Material and Methods: A retrospective investigation of PDAC patients who underwent curative-intended surgery during the period 2008 to 2019 was performed at our institution. (3) Results: We identified 571 of 660 (86.5%) resected patients with well-annotated reports and complete datasets. Of those, 531 patients (93%) exhibited tumors with perineural invasion (Pn1), while 40 (7%) were negative for PNI (Pn0). The majority of patients in the Pn1 group presented advanced tumor stage and positive lymph node infiltration. Patients in the Pn0 group showed an improved disease-free and long-term survival compared to the Pn1 group (p < 0.001). Subgroup analysis of all R0-resected patients indicated improved long-term survival and disease-free survival of R0 Pn0 patients when compared to R0 Pn1 patients (p < 0.001). (4) Conclusion: Our study confirmed that Pn0 improves the long-term survival of PDAC-resected cancer patients. Furthermore, PNI significantly challenges the long-term survival of formally curative (R0) resected patients. We provide new insights into the dynamics of PNI in pancreatic cancer patients which are needed to define subgroups of patients for risk stratification and multimodal treatment strategies.

Predictive preoperative clinical score for patients with liver-only oligometastatic colorectal cancer

BackgroundResection of liver metastases from colorectal cancer (CRC) in the oligometastatic stage improves survival and is a potentially curative treatment. Thus, predictive scores that reliably identify those patients who especially benefit from surgery are essential.Patients and methodsIn this multicenter analysis, 512 patients had undergone surgery for liver metastases from CRC. We investigated distinct cancer-specific risk factors that are routinely available in clinical practice and developed a predictive preoperative score using a training cohort (TC), which was thereafter tested in a validation cohort (VC).ResultsInflammatory response to the tumor, a right-sided primary tumor, multiple liver metastases, and node-positive primary tumor were significant adverse variables for overall survival (OS). Patients were stratified in five groups according to the cumulative score given by the presence of these risk factors. Median OS for patients without risk factors was 133.8 months [95% confidence interval (CI) 81.2-not reached (nr)] in the TC and was not reached in the VC. OS decreased significantly for each subsequent group with increasing number of risk factors. Median OS was significantly shorter (P < 0.0001) for patients presenting all four risk factors: 14.3 months (95% CI 10.5 months-nr) in the TC and 16.6 months (95% CI 14.6 months-nr) in the VC.ConclusionsIncluding easily obtainable variables, this preoperative score identifies oligometastatic CRC patients with prolonged survival rates that may be cured, and harbors potential to be implemented in daily clinical practice.

Expression of Neighbor of Punc E11 (NOPE) in early stage esophageal adenocarcinoma is associated with reduced survival

Current recommendations suggest neoadjuvant treatment in node-positive esophageal cancer or tumors staged T3 and upwards but some T2 N0 patients might benefit from neoadjuvant therapy. It is of clinical relevance to identify this subgroup. Loss of epithelial apicobasal polarity is a key factor in the development of invasive capabilities of carcinoma. The oncofetal stem/progenitor cell marker NOPE is expressed in adult depolarized murine hepatocytes and in murine/human hepatocellular carcinoma. We analyzed NOPE expression in 363 patients with esophageal adenocarcinoma using an RNA Scope Assay on a tissue microarray and correlated results with clinical data. Median follow-up was 57.7 months with a 5-year survival rate of 26.6%. NOPE was detectable in 32 patients (8.8%). In pT1/2 stages, NOPE expression was associated with a significantly reduced median OS of 6.3 months (95% CI 1.2–19.4 months), the median OS is not reached in the NOPE-negative group (calculated mean OS 117.1 months) (P = 0.012). In advanced tumor stages, a NOPE dependent survival difference was not detected. This is the first report of NOPE expression demonstrating a prognostic value in esophageal cancer. Early stage, NOPE positive patients are at a high risk of tumor progression and may benefit from neoadjuvant treatment analogous to advanced stage cancer.

Three-year follow-up of de-escalated axillary treatment after neoadjuvant systemic therapy in clinically node-positive breast cancer: the MARI-protocol

PurposeIn clinically node-positive (cN+) breast cancer patients, evidence supporting response-guided treatment after neoadjuvant systemic therapy (NST) instead of axillary lymph node dissection (ALND) is increasing, but follow-up results are lacking. We assessed three-year axillary recurrence-free interval (aRFI) in cN+ patients with response-adjusted axillary treatment according to the ‘Marking Axillary lymph nodes with Radioactive Iodine seeds’ (MARI)-protocol.MethodsWe retrospectively assessed all stage II–III cytologically proven cN+ breast cancer patients who underwent the MARI-protocol between July 2014 and November 2018. Pre-NST axillary staging with FDG-PET/CT (less- or more than four suspicious axillary nodes; cALN < 4 or cALN ≥ 4) and post-NST pathological axillary response measured in the pre-NST largest tumor-positive axillary lymph node marked with an iodine seed (MARI-node; ypMARI-neg or ypMARI-pos) determined axillary treatment: no further treatment (cALN < 4, ypMARI-neg), axillary radiotherapy (ART) (cALN < 4, ypMARI-pos and cALN ≥ 4, ypMARI-neg) or ALND plus ART (cALN ≥ 4, ypMARI-pos).ResultsOf 272 women included, the MARI-node was tumor-negative in 56 (32%) of 174 cALN < 4 patients and 43 (44%) of 98 cALN ≥ 4 patients. According to protocol, 56 (21%) patients received no further axillary treatment, 161 (59%) received ART and 55 (20%) received ALND plus ART. Median follow-up was 3.0 years (IQR 1.9–4.1). Five patients (one no further treatment, four ART) had axillary metastases. Three-year aRFI was 98% (95% CI 96–100). The overall recurrence risk remained highest for patients with ALND (HR 4.36; 95% CI 0.95–20.04, p = 0.059).ConclusionsDe-escalation of axillary treatment according to the MARI-protocol prevented ALND in 80% of cN+ patients with an excellent three-year aRFI of 98%.

Abstract P5-04-04: Identification of AR driven tumors within TNBC using a novel gene signature

Abstract Background The androgen receptor (AR) is an emerging biomarker and favourable therapeutic target in breast cancer (BC), especially in Triple negative BC (TNBC) which lacks a targeted treatment and shows high molecular heterogeneity. Proportion of AR positive tumours are known to vary (10 to 43%) within TNBC and recent multi-institutional study on AR positive TNBC, showed AR protein status alone is not a reliable prognostic marker for therapeutic response. A deeper examination of AR regulated pathways is necessary to derive AR regulated gene signatures which could identify TNBC tumours truly driven by AR and amenable to anti androgen therapies. In this study, we attempted to develop AR regulated gene signature using gene expression data derived from cell lines under the influence of androgens using systematic bioinformatic approach and tested the ability of the signature to identify AR regulated tumours within TNBC. Methods Microarray data of AR positive BC cell lines (GSE61368 &amp; GSE28305) was used to derive AR regulated genes by a bioinformatic pipeline, using integrated method by incorporating protein interaction networks, topological parameters, and semantic similarity to arrive at final set of 16 genes. Correlation of these genes with AR protein status by reverse phase protein array (RPPA) was evaluated in 447 tumors of TCGA dataset. A 3rd quartile cut-off in the AR expression (by RPPA) was used to classify them as AR positive and negative and a logistic regression model was constructed using positive AR as determinant to generate AR probability score with minimum set of genes. 3rd quartile cut-off in the probability score was used to classify tumors as AR high and low. Distribution of AR probability score was examined in 144 and 187 TNBC tumors in TCGA and METABRIC, respectively. Comparisons between AR high and low tumors were done for clinical parameters, mutational spectrum, expression of ER regulated genes (FOXA1, GATA3 and TFF1) and EMT gene signatures (Byers et al., 2013, Tan et al., 2014). Luminal androgen receptor (LAR) subtype identification by TNBCtype (Lehmann et. al) was done in both datasets to examine the overlap with our method of identification of AR driven tumors within TNBC. Results Logistic regression model identified 5 (SOCS2, ID1,PIP,GADD45 and ZNF689) of the 16 AR regulated genes as predictors for AR probability score which ranged from 0.009 to 0.68 in 144 TNBC tumors within TCGA data. 41/144 (29%) TNBC tumors were categorized as having AR high at cut off of 0.13. The AR probability score ranged from 0.04 to 0.64 in 187 TNBC tumors within METABRIC dataset and 47/187 (25%) were classified as AR driven tumors at cut off of 0.22. Though differences in the clinical variables like age , tumor size and lymph node(LN) status were not different between the AR high and low groups in the TCGA dataset, a significant increase in age, LN positive tumors was observed in the AR high groups in METABRIC. A significant higher PIK3CA mutations was observed in the AR high tumors both in the TCGA and METABRIC (p=0.012 and p&amp;lt;0.0001 respectively) with a proportionate lower p53 mutations in the AR high tumors in both data sets (p=0.03 and p=0.35 respectively). Further, AR high tumors showed significant higher expression of ER regulated genes (TCGA-p&amp;lt;0.05 &amp; METABRIC, p&amp;lt;0.05), were more epithelial by EMT score (TCGA-p&amp;lt;0.05 &amp; METABRIC, p&amp;lt;0.05). Analysis by TNBCtype showed that 30% of AR high tumors in TCGA and 40% of AR high tumors in METABRIC were identified as belonging to LAR subgroup (Lehmann et al). Conclusion Identification of AR driven tumors within TNBC has both prognostic and predictive utility. Methods using limited number of AR regulated genes could be easily applied to larger BC cohorts to identify TNBC tumours driven by AR signalling and may respond well to anti-androgen therapies. Citation Format: Savitha Rajarajan, Snijesh V.P, Maalavika Pillai, Mohit Kumar Jolly, Jyothi S Prabhu. Identification of AR driven tumors within TNBC using a novel gene signature [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 P5-04-04.

Abstract P2-08-06: Defining transcriptomic profiles of breast cancer with early lymph node metastases: A FLEX database sub-study

Abstract Introduction: Early lymph node (LN) metastasis often precedes systemic metastasis and corresponds with a 35% decrease in 10-year survival compared to patients without LN metastasis. Understanding biologic pathways involved in early LN metastasis could identify promising drug targets for early-stage breast cancer (EBC) treatment. While tumor size modestly correlates with the probability of clinical or occult axillary metastases, small T1 tumors are often found to have LN metastases, while many large T3 tumors are often LN negative. We compared large tumors without evidence of LN metastasis (pT2-3N0) and small tumors with LN metastasis (pT1N1-3) by whole transcriptome analysis to elucidate molecular biological differences associated with the presence or absence of early LN metastasis at diagnosis. Methods: The FLEX study enrolls patients with EBC who undergo standard of care MammaPrint (MP) and BluePrint (BP) testing, and consent to clinically annotated full transcriptome data collection. MP classifies tumors as having High Risk (HR) or Low Risk (LR) of distant recurrence. MP combined with BP subtype tumors as either Luminal A-type (MP LR; 56.8%), Luminal B-type (MP HR; 36.4%), HER2-type (1.5%), or Basal-type (5.3%). In our primary comparison, 355 patients had small, LN-positive tumors (pT1N1-3), and 235 had large, LN-negative tumors (pT2-3N0). Control groups consisted of small, LN-negative (pT1N0; n=1384) and large, LN-positive tumors (pT2-3N1-3; n=375). R package ‘limma’ was used for quantile normalization and differential gene expression (DGE) analyses. Differentially expressed genes (DEGs) with a false discovery rate &amp;lt; 0.05 and fold change &amp;gt; 1.4 were considered significant for this exploratory analysis. Gene set enrichment analysis (GSEA) was performed using the Hallmark gene sets (MSigDB). Results: Principal component analysis of each sample’s transcriptional profile revealed more gene profile differences between MP risk and BP subtype than by pathological stage. Overall, DGE analysis comparing pT2-3N0 to pT1N1-3 identified 30 DEGs; of which MUCL1 had a &amp;gt; 2-fold decrease. Within MP LR and BP Luminal A-type tumors, no DEGs were identified comparing pT2-3N0 to pT1N1-3. HR tumors had 73 DEGs (33 upregulated and 40 downregulated); two of 40 downregulated genes, including MUCL1, had &amp;gt; 2-fold change. Within Luminal B tumors, 34 DEGs were identified when comparing pT2-3N0 with pT1N1-3, although none had &amp;gt; 2-fold change. Basal and HER2 tumors were not analyzed due to small numbers. GSEA showed upregulated proliferation and oxidative phosphorylation pathways, and downregulated epithelial to mesenchymal transition (EMT) and immune signatures in pT2-3N0 relative to pT1N1-3 tumors overall, within HR, and Luminal B tumors. Conclusion: This study provides a foundation for understanding the mechanisms that promote LN metastasis. Studies have previously correlated LN metastasis with EMT, immune function, and gene overexpression (BCL2L1, AURKA, CDKN2A, MCL1, MYC). While we did not find significant differences in these genes, our results indicated similar differentially regulated pathways. Overall, we found most biological differences within MP HR and Luminal B tumors. Proliferation-related pathways were upregulated and EMT and immune-related pathways were downregulated in pT2-3N0 tumors compared with pT1N1-3 tumors, suggesting these pathways distinguish small, node-positive tumors from large, node-negative tumors and are involved in early LN metastasis. Interestingly, MUCL1 which has been reported to promote migration and invasion in breast cancer, was consistently downregulated in pT2-3N0 relative to pT1N1-3 tumors. Future studies will investigate antineoplastic therapies for EBC that modulate these dysregulated pathways to reduce early LN metastasis and subsequent systemic metastasis. Citation Format: Nibash Budhathoki, Faisal Fa'ak, Nina D'Abreo, Shubhada Dhage, Phyu Phyu Soe, Dennis Holmes, Josien Haan, Shiyu Wang, Patricia Dauer, Andrea Menicucci, William Audeh, Douglas K Marks. Defining transcriptomic profiles of breast cancer with early lymph node metastases: A FLEX database sub-study [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 P2-08-06.

Abstract P1-05-03: Integrating spatial transcriptomics and high-resolution morphological annotation to investigate tumor heterogeneity and PAM50 molecular subtyping in lobular breast cancer

Abstract Background: Invasive lobular breast carcinoma (ILC) represents 5 to 15% of all invasive breast cancers (BCs). Here, we aim to investigate inter- and intra-tumor heterogeneity in terms of microenvironment composition, PAM50 molecular classification and proliferation (genomic grade index [GGI]) by combining spatial transcriptomics (ST) and accurate morphological annotation. Methods: Spatial RNA sequencing (Visium - 10X Genomics) was performed on frozen tumor samples from 15 primary estrogen receptor positive, HER2-negative ILC patients with long-term follow up. Hematoxylin/eosin slides were morphologically annotated integrating manual and machine learning-based approaches reaching single-cell resolution (QuPath software). The relative histomorphological categories (HC) composition of each spot across the ST slide was computed as percentage of pixels, while the level of proximity of different HC was evaluated computing the proportion of co-occurring HC at each spot. The PAM50 subtypes (AIMS R package) and GGI were computed on spots containing at least 40% of tumor (merging all the spots belonging to each sample [pseudo-bulk] for PAM50, while calculating mean and standard deviation [SD] across spots for GGI). PAM50 was also computed on the pseudo-bulk of the whole set of spots per sample. Wilcoxon and Spearman rank tests were used to compare continuous variables and assess correlations. Results: Out of 15 tumors, 7 were T2 or T3, 6 were node positive at diagnosis and 14 were grade 2. Four patients experienced disease relapse. Morphological annotation revealed that an average (per patient) of 20.3% (5.6-46.7%), 65.9% (45.5-83.5%) and 6.5% (0.0-27.1%) of the spots corresponded to tumor, stroma and fat tissue respectively. Larger tumors (T2-3 vs T1) presented a higher proportion of fat tissue and tumor cells, although these differences did not reach statistical significance. The levels and spatial variability of proliferation, measured using GGI, were higher in T2-3 compared to T1 tumors (p = 0.072 and 0.040, respectively). Of note, higher spatial variability of proliferation was also associated with node-positive tumors (p = 0.066). By computing the PAM50 classification using the pseudo-bulk, 9 samples were classified as luminal A, 1 as luminal B and 5 as normal-like. Of interest, when focusing on the tumor enriched spots, 60% of the samples previously classified as normal-like were re-classified as luminal A. Samples from patients who relapsed showed a higher fraction of fat tissue at the level of the whole slide (14.4% vs 3.5%; p = 0.018), with an increased co-localization of fat tissue and tumor cells at the spot level as well as higher proliferation values, although not significant. Conclusions: High proportion of fat tissue together with higher co-localization of fat tissue with tumor cells are associated with poor outcome in ILC. Higher spatial variability of proliferation is associated with larger tumors, lymph node positivity and recurrence. The proportion of stroma and fat tissue affected substantially the PAM50 classification of the tumors. Further validation is needed. Citation Format: Matteo Serra, Laetitia Collet, Mattia Rediti, Frédéric Lifrange, David Venet, Xiaoxiao Wang, Delphine Vincent, Ghizlane Rouas, Danai Fimereli, David Gacquer, Andrea Joaquin Garcia, Isabelle Veys, Ligia Craciun, Denis Larsimont, Miikka Vikkula, François Duhoux, Françoise Rothé, Christos Sotiriou. Integrating spatial transcriptomics and high-resolution morphological annotation to investigate tumor heterogeneity and PAM50 molecular subtyping in lobular breast cancer [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 P1-05-03.

Abstract ES1-1: Escalating and de-escalation - titrating the right regimen in early stage HER2 positive

Abstract In HER2+ early breast cancer (EBC), treatment concepts so far do not differ according to hormone receptor (HR) status except for adding adjuvant endocrine therapy (ET) in HR+. Nevertheless, preclinical research shows that molecular subtype distributions differ between HR+ and HR- HER2+ with HER2-enriched subtype being more frequent in HR-. In the context of anti-HER2 therapy the clinical impact of biomarkers such as PIK3CA mutations also differs between HR+ and HR-. Moreover, in the neoadjuvant setting, pCR rates differ between HR+ and HR- HER2+ EBC with lower rates in HR+. Yet, the prognostic impact of pCR on outcome in HR+ HER2+ is less pronounced than in HR- HER2+ tumors. Standard therapy for small tumors (pT1 pN0) includes primary surgery followed by adjuvant weekly paclitaxel and 1y trastuzumab, independent of HR status. In all larger node-negative and in node-positive tumors, neoadjuvant chemotherapy with dual HER2 blockade is recommend. Adjuvant therapy is then individualized based on pCR status with antibody therapy continued for 1y in case of pCR and 14 cycles of T-DM1 in case of non-pCR. Based on the ExteNET trial, 1y neratinib is approved as an extended adjuvant anti-HER2 therapy. In Europe, the approval is restricted to high-risk HR+ HER2+ EBC within 1y after trastuzumab therapy based on ExteNET subgroup analyses. Escalation of the endocrine component in high-risk HR+ HER2+ EBC is currently evaluated in eMonarcHER2 by adding abemaciclib to T-DM1 and ET after non-PCR. Regarding de-escalation, TBCRC0023, one of the first chemotherapy-free de-escalation studies in HER2+ EBC, looked at duration of neoadjuvant trastuzumab and lapatinib - in HR+ tumors together with letrozole (+ GNRH if premenopausal). Longer therapy duration led to higher in-breast pCR rates, particularly in the ER+ subgroup (33% after 24 vs. 9% after 12 weeks). WSG ADAPT was the first subtype-specific umbrella trial aiming at tumor-biology adapted therapy de-escalation in EBC; all neoadjuvant sub-trials evaluated 12 weeks of preoperative therapy and allowed patients with a pCR to omit further standard chemotherapy. For HR+/HER2+, there are two neoadjuvant trials, ADAPT TP (triple-positive) and TP II, so far. In ADAPT TP, 4x T-DM1 led to a total pCR (breast and nodes) of 41% - independent of concomitant ET, whereas trastuzumab + ET only rendered 15%. pCR was prognostic for outcome; in patients with pCR, further standard chemotherapy did not improve survival. In TP II, 12x weekly paclitaxel + trastuzumab + pertuzumab achieved a total pCR rate of 57%, whereas the antibodies alone + ET rendered 24%. Individualizing therapy by escalation or de-escalation holds great promise in HER2+ EBC, but the full potential of taking HR-status into account for such strategies has not yet been explored. We now know that a pCR achieved with a de-escalated regimen is clinically meaningful and that de-escalation trials are safe for participating patients in HR+ HER2+ EBC - provided patients and physicians have the option for therapy escalation if clinically needed. The neoadjuvant strategy offers an ideal setting for de-escalation and escalation concepts based on pCR status as well as on early response assessment by biomarkers and conventional or molecular imaging. Optimal endpoints in HR+ HER2+ disease differ according to molecular subtype. As demonstrated in ADAPT TP, HER2-enriched subtype is associated with high pCR rates after HER-targeting regimens whereas luminal A and B subtypes have lower pCR rates. In luminal tumors, survival endpoints may thus be more appropriate to fully evaluate de-escalated regimens.In clinical routine, individualized therapy concepts including therapy de-escalation and escalation should always be evidence-based in order not to jeopardize the already excellent survival rates we have achieved over the last decade in HR+ HER2+ EBC. Citation Format: Escalating and de-escalation - titrating the right regimen in early stage HER2 positive [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 ES1-1.