1 University of Heidelberg, Department of Gynecology and Obstetrics, Heidelberg; 2 Institute for Gynecological Oncology, Mannheim; 3 University of Heidelberg, Department of Internal Medicine V, Heidelberg; 4 University of Heidelberg, Department of Pathology, Heidelberg; 5 University of Heidelberg, Coordination Center for Clinical Trials, Heidelberg; 6 University of Düsseldorf, Department of Hematology and Oncology, Düsseldorf, Germany
* Correspondence to: Dr A. Schneeweiss, University of Heidelberg, Department of Gynecology and Obstetrics, Vossstrasse 9, D-69115 Heidelberg, Germany. Tel: +49-6221-567856; Fax: +49-6221-567920; Email: andreas_schneeweiss{at}med.uni-heidelberg.de
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Abstract |
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Patients and methods: Ninety-one HRPBC patients (73 patients with 10 involved axillary lymph nodes (ALN), 18 premenopausal women with
4 involved ALN) received one cycle (eight patients) or two cycles of HDCT and ASCT. Bone marrow aspiration was performed before systemic treatment to search for MMC using a cocktail of four monoclonal epithelial-specific antibodies (5D3, HEA125, BM7 and BM8). The influence of MMC and other prognostic factors on disease-free survival (DFS), distant DFS (DDFS), and overall survival (OS) was analysed.
Results: In 23 of 91 patients (25%) we detected a median of three MMC (range, 143) among 106 mononuclear cells. With a median follow-up of 62 months (range, 10117), the detection of MMC was not associated with DFS (P=0.929), DDFS (P=0.664) or OS (P=0.642). In multivariate analysis the strongest predictor was nodal ratio for DFS (P=0.012) and expression of p53 for OS (P <0.001).
Conclusion: The detection of MMC at diagnosis has no impact on survival in HRPBC patients treated with HDCT and ASCT.
Key words: high-dose chemotherapy, micrometastatic bone marrow cells, primary breast cancer, prognostic impact, survival
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Introduction |
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Detection of micrometastatic bone marrow cells (MMC) at diagnosis has been identified as an independent prognostic factor of primary breast cancer in several studies [915
]. Other investigators, however, did not find any impact of these cells on survival, either in univariate analysis or after adjustment for established prognostic factors [16
19
]. Furthermore, no data are available on the subgroup of HRPBC patients with extensive axillary lymph node (ALN) involvement, in particular for those who received HDCT with ASCT.
In order to elucidate the prognostic value of MMC in this distinct subgroup of HRPBC patients, we prospectively evaluated the impact on DFS, distant DFS (DDFS), and OS together with all established and a panel of potential prognostic factors in 91 primary breast cancer patients with extensive ALN metastases who received stem cell-supported HDCT at the University of Heidelberg between 1992 and 1999.
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Patients and methods |
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Cytotoxic and endocrine therapy (Figure 1)
In 80 patients induction chemotherapy consisted of two cycles (78 patients) or three cycles (two patients) of ifosfamide 2500 mg/m2 on days 13 and epirubicin 40 mg/m2 on days 13, repeated on day 22. Ten patients received one cycle (seven patients) or two cycles (three patients) of paclitaxel (Taxol) 45 mg/m2 on days 13, ifosfamide 2000 mg/m2 on days 13 and epirubicin 30 mg/m2 on days 13, repeated on day 22. In one patient, induction chemotherapy consisted of three cycles of epirubicin 90 mg/m2 on day 1 and cyclophosphamide 600 mg/m2 on day 1, repeated on day 22.
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The first stem cell-supported HDCT followed 4 weeks after the last cycle of induction chemotherapy. As scheduled, the HDCT consisted of two cycles of peripheral blood stem cell-supported high-dose ifosfamide 12 000 mg/m2 and epirubicin 180 mg/m2 in three patients and high-dose ifosfamide 12 000 mg/m2, epirubicin 180 mg/m2 and carboplatin 900 mg/m2 in 75 patients. Due to toxicity in five patients the regimen of the second course of HDCT was changed (one patient received cyclophosphamide 6000 mg/m2 instead of ifosfamide and four patients received high-dose paclitaxel 180 mg/m2, etoposide 1500 mg/m2 and thiotepa 600 mg/m2). Eight patients were withdrawn from the study after the first cycle of HDCT. The reasons for withdrawal were refusal to proceed in four patients, severe hemorrhagic colitis in one patient, severe neurologic disturbances in one patient, alloreactive antibodies against platelets and no appropriate cross-matched donors available in one patient and retrospectively pre-existing chronic hepatitis B in one patient. The median time interval between the first and second cycle of HDCT was 7 weeks (range, 416). Peripheral blood stem cells were reinfused 48 h after the end of HDCT, and no cytokines were given following transplantation. The patients received prophylactic antimicrobial therapy with ciprofloxacin (1000 mg/day) and fluconazole (400 mg/day).
To treat hormone receptor-positive tumors, premenopausal patients additionally received goserelin 3.6 mg subcutaneously (s.c.) once a month starting from the first cycle of induction chemotherapy for 2 years or until the disease relapsed. Postmenopausal patients received tamoxifen 2030 mg/day orally (p.o.) starting at least 6 weeks after the last peripheral blood stem cell-supported HDCT for 5 years or until the disease relapsed.
After primary therapy, patients had regular check-ups at our hospital that included a careful history and thorough clinical examination every 3 months, as well as chest radiograph and liver ultrasound every 6 months and a bone scan every year.
Locoregional radiotherapy
All patients who underwent breast-conserving surgery received locoregional radiotherapy of the breast at a dose of 50 Gy with a boost of 10 Gy to the tumor bed. For patients undergoing modified radical mastectomy, there was no general recommendation for radiotherapy of the chest wall and draining lymph nodes at the beginning of the trial. From August 1996 on, locoregional irradiation was included in the protocol for all patients. As a result, 41 of 59 (69%) patients who received a mastectomy underwent locoregional radiotherapy of the chest wall. In 75 patients radiotherapy to the draining lymph nodes was administered.
Statistical analysis
DFS, DDFS and OS were taken as clinical outcome variables. DFS was measured from the start of induction chemotherapy until the time of relapse, death or last contact. DDFS was measured from the start of induction chemotherapy until the time of distant relapse, death or last contact. Distant relapse was defined as relapse other than in the ipsilateral breast, ipsilateral chest wall, ipsilateral ALN or above the ipsilateral clavicle. OS was calculated from the start of induction chemotherapy to death or to the date of the last patient contact. Survival curves were estimated using the KaplanMeier product limit method [21]. Univariate and multivariate analyses were performed to identify risk factors associated with DFS, DDFS and OS. Differences between the survival curves were compared using the log rank test [22
]. The following risk factors were examined in a univariate analysis: age at diagnosis (<35 years versus 3545 years versus >45 years), menopausal status (pre- versus postmenopausal), tumor size (pT1 versus pT2 versus pT3 versus pT4), number of involved ALN (<10 versus 1019 versus >19), nodal ratio (<0.8 versus
0.8), stage (II versus III), grade (G1 versus G2 versus G3), combined hormone receptor status (ER or PR positive versus ER and PR negative), Her2/neu expression (02+ versus 3+), proportion of p53-positive tumor nuclei on primary tumor section (
50% versus >50%), Bcl-2 expression (01 + versus 23+), proportion of Ki67-positive tumor nuclei on primary tumor section (
50% versus >50%), S-phase fraction (
4.9% versus >4.9%), DNA index (
1.5% versus >1.5%), presence of MMC (no versus yes), surgical procedure (breast-conserving surgery with adjuvant radiotherapy of the breast versus mastectomy), and adjuvant locoregional radiotherapy of the chest wall or draining lymph nodes (yes versus no). Variables that showed statistical significance in univariate analysis (P <0.05) were included in a multivariate analysis [23
]. Model selection was performed using forward selection (entry into the model if P <0.1) and backward selection (removal from the model if P> 0.1). All tests were performed using SAS software (version 8.2; Cary, NC).
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Results |
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Prognostic impact of MMC
In 23 of 91 patients (25%), we detected a median of three MMC (range, 143) among 106 normal mononuclear bone marrow cells. Characteristics of patients with and without detection of MMC are given in Table 1. In univariate analysis the detection of these cells had no impact on DFS (P=0.929), DDFS (P=0.664) or OS (P=0.642). The corresponding DFS, DDFS and OS curves according to the presence or absence of MMC are shown in Figure 2A.
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In multivariate analysis only nodal ratio <0.8 remained an independent predictor of longer DFS [relative risk (RR)=1.8 (95% confidence interval (CI) 1.142.85); P=0.012] and lower UICC stage for longer DDFS [RR=1.9 (95% CI 1.133.14); P=0.015]. The only independent prognostic factor for a longer OS was lower expression of p53 [RR=5.0 (95% CI 2.012.3); P <0.001].
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Discussion |
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So far, five studies with median follow-up periods of between 34 and 54 months reported an independent impact of MMC on OS considering all established prognostic factors [912
, 14
]. In addition, a recently reported pooled analysis considering data of 4199 primary breast cancer patients from eight trials confirmed the independent prognostic impact of MMC on survival with a median follow-up of 58 months [15
]. Most patients in these studies, however, had no or minimal ALN involvement, and neither in the single trials nor the pooled dataset was a separate analysis performed on the subgroup of patients with extensive ALN involvement, comparable to the patients in our cohort. The patients in our trial probably represent a certain subgroup with near-site metastatic disease, in which the detection of MMC no longer distinguishes between high and low risk for relapse and death.
Fields et al. [24] reported a correlation between micrometastatic bone disease detected by polymerase chain reaction for K19 and earlier relapse in 83 patients with stage IIIV breast cancer undergoing induction chemotherapy followed by stem cell-supported HDCT. Along the same line, Vredenburgh et al. [25
] found an association between MMC detected with a panel of four anti-breast cancer monoclonal antibodies and DFS and OS in 83 HRPBC with at least 10 positive nodes who also received induction treatment followed by HDCT with ASCT. Both investigations, however, examined bone marrow aspirated after induction chemotherapy, i.e. they searched for chemotherapy-resistant MMC, while we analysed bone marrow aspirated before any systemic treatment was initiated. Chemotherapy-resistant MMC represent a selected subpopulation of occult bone metastases that might carry a worse prognosis [26
].
Evaluating the established prognostic factors used to distinguish prognostic groups in the adjuvant setting in combination with nodal ratio, Her2/neu, p53, Bcl-2, Ki67, S-phase fraction, DNA index, surgical procedure, locoregional radiotherapy and presence of MMC, only nodal ratio 0.8 proved to be an independent predictor of shorter DFS in the current analysis [RR=1.80 (95% CI 1.142.85); P=0.004]. Considering 23 variables in 176 HRPBC patients with at least four involved ALN or inflammatory breast cancer treated with HDCT and ASCT, Nieto et al. [27
] determined an axillary nodal ratio of
0.8, negative hormone receptors, and larger tumors (
2 cm versus 25 cm versus >5 cm) to be independent predictors for earlier relapse. The subsequent analysis in which the prognostic value of Her2/neu was evaluated in a subgroup of 146 patients revealed a significantly poorer relapse-free survival (RFS) and OS in case of Her2/neu overexpression. After adjustment for nodal ratio, hormone receptor status and tumour size, Her2/neu overexpression remained an independent predictor for earlier relapse and death [28
]. Probably due to the small number of patients with available Her2/neu status (n=80) we only found a significant association with earlier death (P=0.03), but no association with earlier relapse in our analysis.
The strongest predictor for shorter OS in this study was an overexpression of p53 in >50% of tumor cells [RR=5.0 (95% CI 2.012.3); P <0.001]. This confirms our results obtained with shorter follow-up [29] and data published by Somlo et al. [30
], who also found p53 overexpression to be associated with inferior RFS and OS following HDCT for HRPBC. Nieto and co-workers, however, could not identify such a correlation [28
]. We have no satisfactory explanation for this discrepancy but, in addition to differences in the conditioning regimen, above all methodological differences in defining p53 mutation, e.g. proportion of p53 overexpressing tumors cells or immunological versus molecular biological analyses, might be responsible.
In conclusion, data from randomized trials evaluating HDCT with ASCT in HRPBC patients are inconclusive so far. Even if a positive trend continues, HDCT might save only a certain subgroup of patients from relapse and ultimately death from the disease. The detection of MMC, however, does not help to define such a subpopulation among patients with extensive ALN involvement. According to this analysis it could be hypothesized that patients with a nodal ratio <0.8 and without p53 and Her2/neu overexpression might have a favorable outcome following HDCT and ASCT and, therefore, might be ideal candidates to further evaluate this approach.
Received for publication May 19, 2004. Revision received June 24, 2004. Accepted for publication June 25, 2004.
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