Elmar Stickeler

HER2 status of circulating tumor cells in patients with metastatic breast cancer: a prospective, multicenter trial

There is a growing body of evidence that HER2 status can change during disease recurrence or progression in breast cancer patients. In this context, re-evaluation of HER2 status by assessment of HER2 expression on circulating tumor cells (CTCs) is a strategy with potential clinical application. The aim of this trial was to determine the HER2 status of CTCs in metastatic breast cancer patients comparing two CTC assays. A total of 254 patients with metastatic breast cancer from nine German university breast cancer centers were enrolled in this prospective study. HER2 status of CTCs was assessed using both the FDA-approved CellSearch® assay and AdnaTest BreastCancer™. Using the CellSearch assay, 122 of 245 (50%) patients had ≥5 CTCs, and HER2-positive CTCs were observed in 50 (41%) of these patients. Ninety of 229 (39%) patients were CTC positive using AdnaTest BreastCancer, and HER2 positivity rate was 47% (42 of 90). The rate of breast cancer patients with HER2-negative primary tumors but HER2-positive CTCs was 32% (25 of 78) and 49% (28 of 57) using the CellSearch assay and AdnaTest BreastCancer, respectively. Considering only those patients who had CTCs on both tests (nxa0=xa062), concordant results regarding HER2 positivity were obtained in 50% of the patients (31/62) (Pxa0=xa00.96, κxa0=xa0−0.006). HER2-positive CTCs can be detected in a relevant number of patients with HER2 negative primary tumors. Therefore, it will be mandatory to correlate the assay-dependent HER2 status of CTCs to the clinical response on HER2-targeted therapies.

Impact of treatment characteristics on response of different breast cancer phenotypes: pooled analysis of the German neo-adjuvant chemotherapy trials

Pathological complete response (pCR) to neoadjuvant treatment correlates with outcome in breast cancer. We determined whether characteristics of neoadjuvant therapy are associated with pCR. We used multi-level models, which accounted for heterogeneity in pCR across trials and trial arms, to analyze individual patient data from 3332 women included in 7 German neoadjuvant trials with uniform protocols. PCR was associated with an increase in number of chemotherapy cycles (odds ratio [OR] 1.2 for every two additional cycles; Pxa0=xa00.009), with higher cumulative anthracycline doses (OR 1.6; Pxa0=xa00.002), higher cumulative taxane doses (OR 1.6; Pxa0=xa00.009), and with capecitabine containing regimens (OR 1.62; Pxa0=xa00.022). Association of pCR with increase in number of cycles appeared more pronounced in hormone receptor (HR)-positive tumors (OR 1.35) than in HR-negative tumors (OR 1.04; P for interactionxa0=xa00.046). Effect of anthracycline dose was particularly pronounced in HER2-negative tumors (OR 1.61), compared to HER2-positive tumors (OR 0.83; P for interactionxa0=xa00.14). Simultaneous trastuzumab treatment in HER2-positive tumors increased odds of pCR 3.2-fold (Pxa0<xa00.001). No association of pCR and number of trastuzumab cycles was found (OR 1.20, Pxa0=xa00.39). Dosing characteristics appear important for successful treatment of breast cancer. Longer treatment, higher cumulative doses of anthracyclines and taxanes, and the addition of capecitabine and trastuzumab are associated with better response. Tailoring according to breast cancer phenotype might be possible: longer treatment in HR-positive tumors, higher cumulative anthracycline doses for HER2-negative tumors, shorter treatment at higher cumulative doses for triple-negative tumors, and limited number of preoperative trastuzumab cycles in HER2-positive tumors.

Epidemiological and molecular aspects of ovarian cancer risk.

Abstract In Western and Northern Europe, as well as in the United States, ovarian cancer represents the third most frequent cancer of the female genital tract with an estimated 191,000 newly diagnosed cases per year worldwide. Due to its insidious onset, the disease is diagnosed in 70% of cases in an advanced stage. Consequently, ovarian cancer is the fifth leading cause of cancer-related deaths in women. Epidemiological and molecular studies reviewed here have identified demographic, geographic, molecular, genetic, endocrine, dietary, and environmental factors, which affect the risk of developing ovarian cancer: ethnic background, tumor suppressor gene mutations in the germline, positive family history, number of full-term pregnancies [odds ratio (OR): 0.17; 95% confidence interval (CI): 0.05–0.54], time spent breast feeding, oral contraceptive use [OR: 0.23; 95% CI: 0.10.50], unexplained infertility (OR: 2.64; 95% CI: 1.10–6.35), tubal ligation and prior hysterectomy (OR: 0.5; 95% CI: 0.2–0.9), dietary factors and obesity (OR: 1.7; 95% CI: 1.1–2.8). This knowledge provides the objective basis for an individual risk assessment for women, which should lead to sophisticated counseling and prevention. It should also help to individualize the therapeutic approach in the event that disease is diagnosed.

PREPARE trial: a randomized phase III trial comparing preoperative, dose-dense, dose-intensified chemotherapy with epirubicin, paclitaxel, and CMF versus a standard-dosed epirubicin-cyclophosphamide followed by paclitaxel with or without darbepoetin alfa in primary breast cancer--outcome on prognosis.

BACKGROUNDnThe objective of this study was to compare the effect of dose-intensified neoadjuvant chemotherapy with that of standard epirubicin plus cyclophosphamide followed by paclitaxel in combination with or without darbepoetin on survival in primary breast cancer.nnnPATIENTS AND METHODSnA total of 733 patients received either four cycles of neoadjuvant epirubicin 90 mg/m(2) plus cyclophosphamide 600 mg/m(2) every 3 weeks followed by four cycles of paclitaxel 175 mg/m(2) every 3 weeks (EC→T), or three cycles of epirubicin 150 mg/m(2) every 2 weeks followed by three cycles of paclitaxel 225 mg/m(2) every 2 weeks followed by three cycles of combination chemotherapy with cyclophosphamide, methotrexate, and fluorouracil (E(dd)→T(dd)→CMF). The patients were randomly assigned to receive darbepoetin or none. The primary objective was to demonstrate a superior disease-free survival (DFS) of E(dd)→T(dd)→CMF compared with EC→T.nnnRESULTSnEstimated 3-year DFS was 75.8% with EC→T versus 78.8% with E(dd)→T(dd)→CMF [hazard ratio (HR) 1.14; P = 0.37] and overall survival (OS) 88.4% versus 91.5% (HR 1.26; P = 0.237). Three-year DFS was 74.3% with darbepoetin versus 80.0% without (HR 1.31; P = 0.061) and OS 88.0% versus 91.8% (HR 1.33; P = 0.139). Patients with a pathologically documented complete response [pathological complete response (pCR)] had a significantly better DFS compared with those without achieving a pCR (estimated 3-year DFS: 89.2% versus 74.9%; HR 2.27; P = 0.001).nnnCONCLUSIONnNeoadjuvant dose-intensified chemotherapy compared with standard chemotherapy did not improve DFS, whereas the addition of darbepoetin might have detrimental effects on DFS.

The MSKCC nomogram for prediction the likelihood of non-sentinel node involvement in a German breast cancer population.

Objective To assess whether the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram for prediction of NSLN metastasis is useful in a German breast cancer population and whether the characteristics of the breast tumor and the sentinel lymph node (SLN) are able to predict the likelihood of non-sentinel lymph node (NSLN) metastasis. Methods A total of 545 patients with primary breast cancer and SLN examination were evaluated. The MSKCC nomogram was applied to 98 patients with a positive SLN who subsequently had completion axillary lymph node dissection (ALND). Predictive accuracy was assessed by calculating the area under the receiver-operator characteristic (ROC) curve. The collective was evaluated by correlating the prevalence of NSLN and SLN metastasis to pathological features. Results The MSKCC nomogram achieved a ROC of 0.58 indicating a bad accuracy of the nomogram. Tumor size, histology, lymphovascular infiltration, multifocality, Her-2-neu positivity, and nuclear grade correlated with the probability of SLN metastasis. Histology and primary tumor localization correlated significantly with the probability of NSLN metastasis. Conclusions The MSKCC nomogram did not provide a reliable predictive model in our study population. However, the likelihood of SLN metastasis correlated with the presumed risk factors and no obvious differences between the MSKCC population and our population could be seen. In order to achieve interinstitutional reproducibility, standardization of surgical procedure and of the pathological assessment of the SLN is desirable.

Response and prognosis after neoadjuvant chemotherapy in 1,051 patients with infiltrating lobular breast carcinoma

AbstractnInvasive lobular carcinomas (ILC) show better clinical behaviour compared with other histological types, but significantly lower pathological complete response (pCR) rates after neoadjuvant chemotherapy (NACT). We investigated whether factors influencing pCR rate in ILC after NACT can be identified and whether clinical outcome is different. 9,020 breast cancer patients from nine German neoadjuvant trials with known histological type were pooled. 11.7xa0% of tumours were ILC. Endpoints were: pCR rate, surgery type and survival. ILC was associated with older age, larger tumour size, lymph node negativity, lower grade and positive hormone-receptor-status (HR). Patients with ILC achieved a significantly lower pCR rate compared with non-ILC patients (6.2 vs. 17.4xa0%, Pxa0<xa00.001). The pCR rate was 4.2xa0% in ILC/HR+/G1-2, 7.0xa0% in ILC with either HR− or G3, and 17.8xa0% in ILC/HR−/G3. Mastectomy rate was higher in ILC compared with non-ILC patients irrespective of response to NACT (pCR: 27.4 vs. 16.6xa0%, Pxa0=xa00.037 and non-pCR: 41.8xa0% vs. 31.5xa0%, Pxa0<xa00.0001). Age and HR independently predicted pCR in ILC. In ILC patients, pCR did not predict distant disease free (DDFS) and loco-regional disease free survival (LRFS), but overall survival (OS). Non-pCR patients with ILC had significantly better DDFS (Pxa0=xa00.018), LRFS (Pxa0<xa00.0001) and OS (Pxa0=xa00.044) compared with non-ILC patients. Patients with ILC had a low chance of obtaining a pCR and this is not well correlated with further outcome. The mastectomy rate was considerably high in ILC patients even after obtaining a pCR. We, therefore, suggest to offer NACT mainly to ILC patients with HR-negative tumours.

Poor outcome in primary non-small cell lung cancers is predicted by transketolase TKTL1 expression

Aim: Malignant tumours ferment glucose to lactate even in the presence of sufficient oxygen (the Warburg effect). Transketolases seem to be involved in this metabolic switch. TKTL1 has previously been shown to encode a transketolase-like enzyme which is overexpressed in colon, urothelial and breast cancer. Here we investigated the prognostic impact of TKTL1 expression in non-small cell lung cancer (NSCLC). Methods: Curatively operated NSCLCs of 201 patients were analysed for TKTL1 expression by immunohistochemistry (clone JFC12T10). Statistical analyses with regard to clinicopathological parameters included Kaplan-Meier and multivariate Cox regression analyses. Results: There was no or mild TKTL1 expression in 89 tumours (44.7%), whereas in 110 tumours (55.3%) TKTL1 was overexpressed. TKTL1 overexpression correlated with tumour-type (pu200a=u200a0.02) and histological grading (pu200a=u200a0.033) and was significantly associated with poor patient survival (pu200a=u200a0.008). In addition, TKTL1 overexpression identified patients with poor clinical outcome among lymph node negative (pu200a=u200a0.039) and well to moderately differentiated (pu200a=u200a0.005) NSCLCs; furthermore, it proved to be an independent prognostic factor (pu200a=u200a0.0252). Conclusion: Our data suggest that TKTL1 overexpression is a new and independent predictor of survival for patients with NSCLC. Since inhibition of transketolase enzyme reactions has recently been shown to effectively suppress tumour growth, TKTL1 represents a novel pharmacodiagnostic marker.

Expression levels of hnRNP G and hTra2-beta1 correlate with opposite outcomes in endometrial cancer biology

HnRNP G is a member of heterogeneous nuclear ribonucleoprotein (hnRNP) family with potent tumor suppressive activities. Human transformer‐2‐beta1 (hTra2‐beta1) belongs to the arginine‐serine rich like proteins and is found over‐expressed in various human cancers. It was recently shown that hnRNP G and hTra2‐beta1 exert antagonistic effects on alternative splicing. In our study we explored the impact of these two factors in tumor biology of endometrial cancer (EC). EC tissues (n = 139) were tested for hnRNP G and hTra2‐beta1 expression on mRNA level by real time PCR and on protein level by immunohistochemistry. HTra2‐beta1 mRNA level was found being induced in advanced International Federation of Gynecology and Obstetrics (FIGO) stages (p = 0.016). HnRNP G protein nuclear expression was found more prominent in patients without distant organ metastases (p = 0.033) and in FIGO Stages I/II group (p < 0.001). HTra2‐beta1 protein nuclear levels were elevated in poorly differentiated (p = 0.044) and lymph node metastases (p = 0.003) cancers. Kaplan‐Meier survival curves revealed that elevated hnRNP G mRNA (p = 0.029) and protein (p = 0.022) levels were associated with a favorable patient outcome. Multivariate Cox‐regression analyses identified nuclear hnRNP G level [hazard ratio (HR) 0.468, p = 0.026) as well as hTra2‐beta1 level (hazard ratio 5.760, p = 0.004) as independent prognostic factors for EC progression‐free survival. Our results indicate that the antagonistic functional effects of hnRNP G and hTra2‐beta1 on alternative splicing correlate directly to their opposite clinical effects on EC patient outcome.

Basal-like molecular subtype and HER4 up-regulation and response to neoadjuvant chemotherapy in breast cancer

Alteration of gene expression profiles during chemotherapy may predict response to neoadjuvant chemotherapy (NAC) in breast cancer patients. In a prospective cohort study of 32 women with primary invasive breast cancer, we obtained tumor specimens before and after 4 cycles of NAC with epirubicine 90xa0mg/m2 and cyclophosphamide 600xa0mg/m2, followed by 4xa0cycles of docetaxel 100xa0mg/m2. Total-RNA was extracted from tumor specimens and the whole transcriptome was analyzed with Agilents 44K single color microarray. Data analysis was performed by GeneSpring v.11 and IBM SPSS v.18. Ten tumors were classified as basal-like and 22 tumors were classified as non-basal-like. Gene expression-based molecular subtype (basal-like vs. non-basal-like) (P=0.003), but not tumor grade (P=0.07), estrogen receptor (P=0.1), progesterone receptor (P=0.6) and HER2 status (P=0.4) predicted pathological complete response to NAC. Specifically, 7/10 basal-like tumors responded to NAC, whereas 19/22 non-basal-like tumors did not respond. Comparing gene expression signatures before and after 4 cycles of NAC, we found that all patients with an initial non-basal-like tumor retained this tumor type, whereas 5/7 basal-like tumors, including all responders, lost this molecular subtype. Complete prediction of response to NAC was achieved with a 21xa0gene list (P=0.000008). Of note, both the expression and up-regulation of a single gene, i.e. HER4, predicted the response to NAC in 26/32 (81%; P=0.002) and in 23/25 (92%; P<0.001) patients, respectively. These preliminary data indicate that therapy-induced HER4 gene up-regulation may be associated with response to NAC with epirubicine, cyclophosphamide and docetaxel.

Immunological Approaches in the Treatment of Metastasized Breast Cancer

A better understanding of tumor biology has led to the development of a number of antibody-based targeted therapies in breast cancer. Several of these newer agents, such as trastuzumab and bevacizumab have demonstrated clinical activity and have improved the treatment of patients with metastatic breast cancer (MBC). Trastuzumab is a monoclonal antibody that binds to the extracellular domain of the HER2 receptor. The addition of trastuzumab to chemotherapy and also to endocrine therapy has enhanced efficacy of treatment. New antibody-based strategies directed against HER2 are under development. These new approaches include pertuzumab, an antibody with a different binding epitope that inhibits dimerization of HER2 with other members of the HER receptor family and TDM1, a trastuzumab-based antibody chemotherapeutic conjugate. Another approach to the treatment of solid tumors is inhibition of angiogenesis. The anti-VEGF antibody bevacizumab has been approved for treatment of MBC. Although the mechanism of action is still under investigation, bevacizumab is tested in other clinical settings such as adjuvant therapy, maintenance therapy, and in combination with both chemotherapy and other targeted agents. In this review, we will summarize the most important studies on trastuzumab and bevacizumab, and describe new antibodies currently under clinical development.