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Introduction Breast cancer is uncommon in men. Almost all male breast cancers are hormone receptor-positive, HER2-negative, although the pathogenesis is not always attributable to an endocrine condition. A few studies have compared biological characteristics or molecular signatures with breast cancers in women. We sought to evaluate whether hormone receptor-related gene expression is different in cancers from men compared to equivalent cancers from women. SET2,3 index measures non-proliferative hormone receptor-related transcriptional activity in the cancer (SET-ER/PR index) and adjusts this for a Baseline Prognosis Index (BPI) that combines the measurements of tumor and nodal stage with a 4-gene molecular subtype (ESR1, PGR, ERBB2, and AURKA). Methods We received aliquots of total RNA from male patients with breast cancer included in the retrospective cohort study of the EORTC 10085/BCG/TBCRC/BIG/NCTN International Male Breast Cancer Program (NCT01101425). SET2,3 assay was performed using the QuantiGene assay (Thermo Fisher) using bead-based hybridization and laser spectroscopy (Luminex). The statistical analyses were performed by the EORTC statistician. The primary objective of the study was the assessment of the prognostic value of the SET2,3 index score in patients with early-stage hormone receptor-positive, HER2-negative male breast cancer, treated with endocrine therapy. Clinical outcomes (recurrence-free survival – RFS; overall survival – OS) were estimated by Kaplan-Meier curves and secondarily compared using multivariable Cox models adjusted for continuous SET2,3 index, tumor size, nodal status, age, and chemotherapy and radiotherapy use. An exploratory analysis to compare the SET2,3 index scores distribution in female and male breast cancer patients was also performed using results from the same assay performed on cancers from women selected on the same inclusion criteria. Due to the low numbers of male patients treated with neoadjuvant treatment (N=6), this analysis was restricted to patients treated with adjuvant treatment (n=315 male and 660 female). Results Of the 321 male patients with breast cancer analyzed, treated between 1990 and 2010, 211 (65.7%) were categorized as high SET2,3 index score, reflecting a high endocrine activity in the cancer and low risk of recurrence, and 110 patients (34.3%) categorized as being low score, reflecting low endocrine activity and high risk of recurrence. At 5 years, the RFS was 75.0% (95% CI, 67.4-81.1) in the high SET2,3 group versus 60.7% (95% CI, 49.1-70.5) in the low SET2,3 group (HR univariate, 0.49; 95% CI, 0.34-0.70; P< 0.0001). The 5-year OS rate among patients with a high SET2,3 index was 84.3% (95% CI, 45.5-73.8), in contrast of 67.8% (95% CI, 56.6-76.7) in the low SET2,3 group (HR univariate, 0.44; 95% CI, 0.30-0.65; P< 0.0001). SET2,3 was independently prognostic for OS, but not RFS in multivariable Cox models. In patients classified as low SET2,3, the addition of neo/adjuvant chemotherapy to adjuvant endocrine therapy was associated with 5-year OS of 76.0% (95% CI, 59.5-86.4) and in patients who received endocrine therapy alone the 5-year OS was 61.3% (95% CI, 45.5-73.8), an absolute difference of 14.7 percentage points. Overall, we did not observe a difference in the distributions (median, interquartile range) of SET2,3 index between men (2.4, 1.9–2.6) and women (2.3, 2.0–2.7). Conclusion SET2,3 index measurements of endocrine-related transcriptional activity in male patients with breast cancer were not different from measurements in female patients with breast cancer. SET2,3 was prognostic in male breast cancer and our exploratory analysis suggests that chemotherapy might improve the poor prognosis for men with breast cancer that has low SET2,3 index. This study was funded by the Breast Cancer Research Foundation (BCRF). Citation Format: Danielle B. Zakon, Coralie Poncet, Fatima Cardoso, Neven Anouk, Vicente Valero, Stefan Aebi, Kim Benstead, Oliver Bogler, Lissandra Dal Lago, Judith Fraser, Carmela Caballero, Ingrid A. Hedenfalk, Larissa A. Korde, Barbro Linderholm, John WM Martens, Lavinia P. Middleton, Melissa Murray, Catherine M. Kelly, Cecilia Nilsson, Monika Nowaczyk, Stephanie Peeters, Melanie Beauvois, Peggy Porter, Carolien P. Schroder, Isabel T. Rubio, Kathryn Ruddy, Christi van Asperen, Danielle Van Den Weyngaert, Carolien HM van Deurzen, Elise van Leeuwen-Stok, Joanna M. Vermeij, John MS Bartlett, Antonio C. Wolff, Sharon H. Giordano, W. Fraser Symmans. PD6-11 Evaluation of the Sensitivity to Endocrine Therapy Index (SET2,3) in Early Male Breast Cancer: Results from an analysis in the EORTC 10085/TBCRC/BIG/NCTN International Male Breast Cancer Program [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD6-11.

Introduction In hormone receptor-positive, HER2-negative early-stage breast cancer (BC), cyclin-dependent kinases 4 and 6 inhibition (CDK4/6i) in combination with endocrine therapy (ET) could represent an alternative to neoadjuvant chemotherapy (NAC). Methods NEOLBC is a randomized phase II trial that tailored neoadjuvant therapy in postmenopausal patients with early, luminal (ER >50%, PR any), HER2-negative, stage II/III BC based on the percentage of Ki67 positive cancer cells after a window of opportunity of two weeks letrozole. Patients with a Ki67 >= 1% after 2 weeks were randomized between ribociclib plus letrozole (RL) and chemotherapy (CT; AC-T regimen). The primary objective was to determine if RL gives a doubling in complete cell cycle arrest (CCCA; Ki67 < 1% on IHC) as compared to CT in the surgical specimen (70% vs. 35% of patients, respectively). Secondary endpoints included pathological response, toxicity and ER pathway activity (measured by the OncoSIGNal qPCR test). Results Out of 161 registered patients, 70 patients were randomized and 66 patients started treatment; 34 RL and 32 CT. Patient characteristics were equally distributed between the two groups, except for the PR status (RL 23.5% negative vs. 50.0% negative in the CT group). In the intention to treat analysis, the CCCA in the surgical specimen was similar for both groups: 35.3% in the RL vs. 31.3% in the CT group (p = 0.73). The pathological complete response (pCR) in the breast was not significantly different between the two groups (11.8% vs. 3.1%, p = 0.36) nor was the pCR rate in breast plus lymph nodes (8.8% vs. 3.1%, p = 0.61) for the RL vs. CT group, respectively. An explorative analysis on the difference in Ki67% (decline, no change, increase) from baseline to surgery showed a decline in 73.5% vs. 50.0%, no change in 17.6% vs. 31.3% and an increase in 8.8% vs. 18.8% of patients (p = 0.06) for the RL vs. CT group, respectively. In the RL group eight patients (23.5%) discontinued ribociclib early due to toxicity (two SAE’s were observed) vs. 10 patients (31.3%) discontinuing treatment in the CT group (one SAE was observed). Secondary endpoints, including the ER pathway activity analysis, will be presented in-depth during the meeting. Conclusion Although the primary endpoint was not met, the NEOLBC trial showed a similar CCCA and pathological response at surgery for RL vs. CT. Therefore, RL as an alternative for NAC merits further investigation in follow-up studies. ClinicalTrials.gov: NCT03283384 Citation Format: Anne Florine de Groot, Danielle Cohen, Joan B. Heijns, Caroline Mandigers, Diederick M. Keizer, Hein Putter, Elma Meershoek-Klein Kranenbarg, Marjolijn Duijm-de Carpentier, Kyra Dijkstra, Elise van Leeuwen-Stok, Gerrit-Jan Liefers, Sabine Linn, Judith Kroep. The use of ribociclib/letrozole combination as an alternative for neoadjuvant chemotherapy in selected patients with early luminal breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-07-07.

Supplementary Data from Differential Survival and Therapy Benefit of Patients with Breast Cancer Are Characterized by Distinct Epithelial and Immune Cell Microenvironments

Purpose:Extensive work in preclinical models has shown that microenvironmental cells influence many aspects of cancer cell behavior, including metastatic potential and their sensitivity to therapeutics. In the human setting, this behavior is mainly correlated with the presence of immune cells. Here, in addition to T cells, B cells, macrophages, and mast cells, we identified the relevance of nonimmune cell types for breast cancer survival and therapy benefit, including fibroblasts, myoepithelial cells, muscle cells, endothelial cells, and seven distinct epithelial cell types.Experimental Design:Using single-cell sequencing data, we generated reference profiles for all these cell types. We used these reference profiles in deconvolution algorithms to optimally detangle the cellular composition of more than 3,500 primary breast tumors of patients that were enrolled in the SCAN-B and MATADOR clinical trials, and for which bulk mRNA sequencing data were available.Results:This large data set enables us to identify and subsequently validate the cellular composition of microenvironments that distinguish differential survival and treatment benefit for different treatment regimens in patients with primary breast cancer. In addition to immune cells, we have identified that survival and therapy benefit are characterized by various contributions of distinct epithelial cell types.Conclusions:From our study, we conclude that differential survival and therapy benefit of patients with breast cancer are characterized by distinct microenvironments that include specific populations of immune and epithelial cells.

Supplementary Table from Differential Survival and Therapy Benefit of Patients with Breast Cancer Are Characterized by Distinct Epithelial and Immune Cell Microenvironments

Supplementary Figure from Differential Survival and Therapy Benefit of Patients with Breast Cancer Are Characterized by Distinct Epithelial and Immune Cell Microenvironments

Introduction: Inflammatory breast cancer (IBC) is a rare ( Citation Format: Jasper JL van Geel, Gonneke van der Schoor, Elise van Leeuwen-Stok, John WM Martens, Saskia M Wilting, Jelle Wesseling, Gabe S Sonke, Carolien P Schröder. Clinicopathological characterization of inflammatory breast cancer in the Netherlands: First results of the prospective INFLAME registry [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 P1-24-03.

Background: The addition of pertuzumab to neoadjuvant trastuzumab-containing chemotherapy significantly improves pathological complete response (pCR) rates in patients with HER2-positive breast cancer. However, effects on long-term survival outcomes have been modest. While prior studies suggest that only a subset of patients benefits most from the addition of pertuzumab, a reliable biomarker for response prediction has not been established. BluePrint is an 80-gene molecular subtyping test that classifies breast tumors as Basal-, Luminal- or HER2-subtype. Recent data shows that some tumors have more than one activated pathway and can be classified as dual subtype. Secondary analyses from the Aphinity trial (NCT01358877) suggest that pertuzumab benefit is largely restricted to patients with single-activated HER2-type tumors and less pronounced in patients with other single- or dual-activated subtypes. In this study, we evaluated BluePrint subtype as a biomarker for predicting response to trastuzumab-containing neoadjuvant chemotherapy with or without pertuzumab in a large nationwide cohort of patients. Methods: We collected data of all patients with stage II-III HER2-positive breast cancer who received neoadjuvant chemotherapy and trastuzumab between January 2013 and January 2016 from the Netherlands Cancer Registry. Pertuzumab was not reimbursed in the Netherlands during this period but was available to patients participating in the TRAIN2 clinical trial (NCT01996267). Pre-treatment biopsies were collected and tumor cell percentage was adequate in 404 patients who received pertuzumab and in 432 matched control patients who did not receive pertuzumab. Matching factors included treatment with anthracyclines (yes vs. no), age and hormone receptor status. BluePrint molecular subtypes were determined sucessfully through microarray in 680 patients. Pathological complete response (pCR) and overall survival (OS) were analyzed by treatment arm and BluePrint subtypes, using logistic and Cox regression analyses. Results: Microarray data was available for 334 patients who received pertuzumab and 346 patients who did not. Tumors were classified as single HER2 (77.6%), Luminal-HER2 (11.3%), single Luminal (8.4%), or other (2.6%). Overall, pCR rate was 65.0% in patients who received pertuzumab and 38.9% in patients who did not. In patients with single HER2-type tumors, pCR rate was significantly higher with pertuzumab (77.0% vs. 46.0%, multivariate adjusted odds ratio [aOR] 3.92, 95% confidence interval [CI] 2.60 - 5.98). In patients with other subtypes, pCR rate was lower overall and not significantly different with or without pertuzumab (23.5% vs. 13.5%, aOR 2.50, 95% CI 0.98 - 6.89). In addition, multivariate Cox regression analyses showed a significant OS benefit with pertuzumab in patients with single HER2-type tumors (adjusted hazard ratio [aHR] 0.33, 95% CI 0.16 - 0.67), but not in other subtypes (aHR 0.94, 95% CI 0.31 - 2.83). However, tests for interactions between pertuzumab and BluePrint subtypes were not significant. Conclusion: We confirmed the results of a prior secondary analysis of the Aphinity trial that the benefit of adding pertuzumab to (neo)adjuvant trastuzumab-based chemotherapy seems most pronounced in patients with a molecularly defined single-activated HER2-subtype. In other subtypes, pathological complete response rates and long-term outcomes are worse overall and no clear benefit of pertuzumab was seen, although tests for interaction between pertuzumab treatment and BluePrint subtype were not significant. Citation Format: Marte C Liefaard, Anna van der Voort, Joyce Sanders, Shiva Vonk, Hugo M Horlings, Sabine Siesling, Linda de Munck, Elise van Leeuwen-Stok, Miranda Kleijn, Lorenza Mittempergher, Midas M Kuilman, Esther H Lips, Gabe S Sonke. Effect of pertuzumab plus neoadjuvant trastuzumab-based chemotherapy in early-stage HER2-positive breast cancer according to BluePrint molecularly defined breast cancer subtypes [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 PD15-07.

In female breast cancer (BC), elastosis is strongly related to estrogen receptor alpha (ERα) expression. Male breast cancers almost invariably express ERα; so, the aim of this study was to investigate elastosis frequency in invasive male BC as well as clinicopathological correlations, in comparison with females. A total of 177 male BC cases and 135 female BC cases were included, all ERα-positive and invasive carcinoma of no special type. Elastosis on H&E-stained slides was scored in a four-tiered system as elastosis grade (EG) 0 (no elastosis) to EG3 (high amount of elastosis). EG scores in male BC were correlated to histopathological characteristics and overall surviva and compared with female BC EG scores. Male BC showed some degree of elastosis in 26/117 cases (22.2%) with none showing EG3, while female BC cases showed elastosis in 89/135 cases (65.9%) with 21.5% showing EG3 (p < 0.001). This difference retained its significance in multivariate logistic regression. In male BC cases, no significant correlations were found between the amount of elastosis and age, grade, mitotic activity index, and PgR. In addition, no significant prognostic value of elastosis was seen. In conclusion, despite high ERα expression, male BC showed significantly less elastosis than female BC. Elastosis did not show clinicopathological correlations or prognostic value. Therefore, elastosis seems to be a less useful ERα tissue biomarker with less clinical significance in male BC compared with females, pointing towards important BC sex differences.

Purpose: Extensive work in preclinical models has shown that microenvironmental cells influence many aspects of cancer cell behavior, including metastatic potential and their sensitivity to therapeutics. In the human setting, this behavior is mainly correlated with the presence of immune cells. Here, in addition to T cells, B cells, macrophages, and mast cells, we identified the relevance of nonimmune cell types for breast cancer survival and therapy benefit, including fibroblasts, myoepithelial cells, muscle cells, endothelial cells, and seven distinct epithelial cell types. Experimental Design: Using single-cell sequencing data, we generated reference profiles for all these cell types. We used these reference profiles in deconvolution algorithms to optimally detangle the cellular composition of more than 3,500 primary breast tumors of patients that were enrolled in the SCAN-B and MATADOR clinical trials, and for which bulk mRNA sequencing data were available. Results: This large data set enables us to identify and subsequently validate the cellular composition of microenvironments that distinguish differential survival and treatment benefit for different treatment regimens in patients with primary breast cancer. In addition to immune cells, we have identified that survival and therapy benefit are characterized by various contributions of distinct epithelial cell types. Conclusions: From our study, we conclude that differential survival and therapy benefit of patients with breast cancer are characterized by distinct microenvironments that include specific populations of immune and epithelial cells.

Introduction: Male breast cancer (BCa) is a rare disease accounting for less than 1% of all breast cancers (BC) and 1% of all cancers in males. The clinical management is largely extrapolated from female BCa. Few studies have examined the genomic landscape of male BCas, with six male BCas included in The Cancer Genome Atlas (TCGA). Familial studies of male BCas have shown genomic changes similar to female BCa, while a larger targeted sequencing study of 59 male breast cancers identified recurrent mutations affecting PIK3CA and GATA3. To date, there is still limited information regarding the genomic landscape of male BCas; particularly in the context of identifying targeted treatments. To reveal genomic changes that characterize male BCas in the context of known cancer driver genes linked to prognosis and targeted agents, we performed a targeted sequencing study on 248 male BCas from the International Male Breast Cancer Program. Methods: 248 primary M0, ER+ve, HER2-ve male BCas enrolled in the Part 1 (retrospective joint analysis) International Male Breast Cancer Program of 1483 patients diagnosed between 1990-2010 (Cardoso et al. Annals of Oncology, 2018) were processed for nucleic acid extraction from formalin-fixed paraffin embedded (FFPE) tissues. Using the Thermo Fisher Scientific Oncomine Comprehensive Assay v3 (OCAv3), a validated targeted sequencing panel currently used in the NCI-MATCH trial (NCT02465060), we evaluated mutational and copy number variations (CNVs) of genes that are prognostic or predictive to targeted therapies currently in use in the clinic or late-stage clinical trials. The OCAv3 DNA pan-cancer panel assays 115 genes for determining mutational status (48 full coding and 67 hotspot) as well as copy-number assessment in 43 genes. The OCAv3 uses Ampliseq-based technology linked to the Oncomine NGS workflow to identify actionable mutations and CNVs Results: Of the 248 samples assayed, 216 passed strict quality control parameters (87.1%). Using the Oncomine NGS workflow, actionable mutations at ≥5% variant allele frequency (VAF) were most frequently identified in PIK3CA (29.2%), BRCA2 (11.1%), NF1 (11.6%), indels in TP53 (10.6%), ATR (5.6%), ATRX (5.1%), indel BRCA2 (5.1%), TP53 point mutations (4.6%), MET (4.6%), ATM (4.6%), NOTCH2 (4.6%), CHEK1 (4.2%), FANCI (4.2%), PTEN (3.2%) with a number of additional genes identified at lower frequencies. Gene amplifications were most frequently detected in MYC (24.5%), FGFR1 (14.8%), CCND1 (12%), FGF3 (9.7%), FGF19 (9.7%), MDM2 (6.5%), CDK4 (1.4%), FGFR3, MDM4, ERBB2 (0.9% each), and FLT3, AR, MYCL, CDK6, IGF1R, FGFR4, KRAS, AKT3 and ESR1 (0.5% each). Although the results here describe the mutations and copy-number changes deemed to be actionable, further analysis of all non-actionable somatic mutations and CNVs will be presented and compared to female BCas previously assayed using the same panel. Conclusion: In this targeted sequencing study of the largest series of male BCas to our knowledge, we have revealed that PIK3CA continues to be a frequently altered gene in both male and female BCas. However, there is an enrichment of mutations in genes related to DNA repair in male BCs. Interestingly, while MYC is commonly amplified in female BCa, a higher frequency of amplified cases were seen in male BCas, in contrast to female BCas. Together with our previously generated transcriptional profiling data in this data set, we believe that both common and unique biological processes comprising male and female BCas will ultimately improve their clinical management and move towards the goal of precision medicine. This work has been funded by the Breast Cancer Research Foundation (BCRF). Citation Format: Jane Bayani, Coralie Poncet, Cheryl Crozier, Quang M Trinh, Megan Hopkins, Aime Lambert Uwimana, Tammy Piper, Carrie Cunningham, Monika Sobol, Stefan Aebi, Kim Benstead, Oliver Bogler, Lissandra Dal Lago, Florentine Hilbers, Ingrid Hedenfalk, Larissa Korde, Barbro Linderholm, John Martens, Lavinia Middleton, Melissa Murray, Catherine Kelly, Cecilia Nilsson, Monika Nowaczyk, Stephanie Peeters, Aleksandra Peric, Peggy Porter, Carolien Schröder, Isabel T Rubio, Kathryn J Ruddy, Christi van Asperen, Danielle Van Den Weyngaert, Carolien HM van Deurzen, Elise van Leeuwen-Stok, Joanna Vermeij, Eric Winer, Lincoln D Stein, Sharon H Giordano, Fatima Cardoso, John MS Bartlett. The genomic landscape of male breast cancers using the oncomine comprehensive assay for actionable mutations [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-10-03.

Male breast cancer (BCa) is a rare disease accounting for less than 1% of all breast cancers and 1% of all cancers in males. The clinical management is largely extrapolated from female BCa. Several multigene assays are increasingly used to guide clinical treatment decisions in female BCa, however, there are limited data on the utility of these tests in male BCa. Here we present the gene expression results of 381 M0, ER+ve, HER2-ve male BCa patients enrolled in the Part 1 (retrospective analysis) of the International Male Breast Cancer Program. Using a custom NanoString™ panel comprised of the genes from the commercial risk tests Prosigna®, OncotypeDX®, and MammaPrint®, risk scores and intrinsic subtyping data were generated to recapitulate the commercial tests as described by us previously. We also examined the prognostic value of other risk scores such as the Genomic Grade Index (GGI), IHC4-mRNA and our prognostic 95-gene signature. In this sample set of male BCa, we demonstrated prognostic utility on univariate analysis. Across all signatures, patients whose samples were identified as low-risk experienced better outcomes than intermediate-risk, with those classed as high risk experiencing the poorest outcomes. As seen with female BCa, the concordance between tests was poor, with C-index values ranging from 40.3% to 78.2% and Kappa values ranging from 0.17 to 0.58. To our knowledge, this is the largest study of male breast cancers assayed to generate risk scores of the current commercial and academic risk tests demonstrating comparable clinical utility to female BCa., SCOPUS: ar.j, info:eu-repo/semantics/published

Background: The addition of bevacizumab to chemotherapy conferred a modest progression-free survival (PFS) benefit in metastatic triple-negative breast cancer (mTNBC). However, no overall survival (OS) benefit has been reported. Also, its combination with carboplatin-cyclophosphamide (CC) has never been investigated. Methods: The Triple-B study is a multicenter, randomized phase IIb trial that aims to prospectively validate predictive biomarkers, including baseline plasma vascular endothelial growth factor receptor-2 (pVEGFR-2), for bevacizumab benefit. mTNBC patients were randomized between CC and paclitaxel (P) without or with bevacizumab (CC ± B or P ± B). Here we report on a preplanned safety and preliminary efficacy analysis after the first 12 patients had been treated with CC+B and on the predictive value of pVEGFR-2. Results: In 58 patients, the median follow-up was 22.1 months. Toxicity was manageable and consistent with what was known for each agent separately. There was a trend toward a prolonged PFS with bevacizumab compared to chemotherapy only (7.0 vs. 5.2 months; adjusted HR = 0.60; 95% CI 0.33–1.08; p = 0.09), but there was no effect on OS. In this small study, pVEGFR-2 concentration did not predict a bevacizumab PFS benefit. Both the intention-to-treat analysis and the per-protocol analysis did not yield a significant treatment-by-biomarker test for interaction (pinteraction = 0.69). Conclusions:CC and CC+B are safe first-line regimens for mTNBC and the side effects are consistent with those known for each individual agent. pVEGFR-2 concentration did not predict a bevacizumab PFS benefit.

Background Breast cancer is rare in men, but management is focused on tumor characteristics commonly found in female breast cancer. The tumor microenvironment of male breast cancer is less well understood, and insight may improve male breast cancer management. The hepatocyte growth factor (HGF)/c-MET axis and the stromal cell-derived factor-1 (CXCL12)/C-X-C chemokine receptor type 4 (CXCR4) axis are prognostic in women with breast cancer. We aimed to investigate these factors in male breast cancer and correlate them with patient survival. Methods From 841 Dutch males with breast cancer who were enrolled in the EORTC 10085/TBCRC/BIG/NABCG International Male Breast Cancer Program (NCT01101425) and diagnosed between 1990 and 2010, archival primary tumor samples were collected. Tissue microarrays were constructed with 3 cores per sample and used for immunohistochemical analysis of HGF, c-MET, CXCL12, and CXCR4. Overall survival (OS) of the patients without metastases (M0) was analyzed using the Kaplan-Meier method. The value of the markers regarding OS was determined using univariable and multivariable Cox regression analyses, providing hazard ratios (HRs) and 95% confidence intervals (95% CIs). Results Of 720 out of 841 patients, sufficient tissue was available for analysis; 487 out of 720 patients had M0 disease. Patients with high HGF expression and high CXCL12 expression had a superior OS (low vs high expression of both markers, 7.5 vs 13.0 years, hazard ratio [HR] 0.64, 95% CI 0.49–0.84, P = 0.001 [HGF]; 9.1 vs 15.3 years, HR 0.63, 95% CI 0.45–0.87, P = 0.005 [CXCL12]). Multivariate analysis identified HGF as an independent predictor for OS (HR 0.64, 95% CI 0.47–0.88, P = 0.001). Conclusions HGF and CXCL12 tumor expression appear to identify male breast cancer patients with a relatively good prognosis. Possibly, this could support male breast cancer-specific management strategies in the future.

Loss of Y-chromosome (LOY) is associated with increased cancer mortality in males. The prevalence of LOY in male breast cancer (BC) is unknown. The aim of this study is to assess the presence and prognostic effect of LOY during male BC progression. We included male BC patients diagnosed between 1989 and 2009 (n = 796). A tissue microarray (TMA) was constructed to perform immunohistochemistry and fluorescent in situ hybridization (FISH), using an X and Y probe. We also performed this FISH on a selected number of patients using whole tissue slides to study LOY during progression from ductal carcinoma in situ (DCIS) to invasive BC. In total, LOY was present in 12.7% (n = 92) of cases, whereby LOY was associated with ER and PR negative tumors (p = 0.017 and p = 0.01). LOY was not associated with the outcome. Using whole slides including invasive BC and adjacent DCIS (n = 22), we detected a concordant LOY status between both components in 17 patients. In conclusion, LOY is an early event in male breast carcinogenesis, which generally starts at the DCIS stage and is associated with ER and PR negative tumors.

textabstractBACKGROUND: To explore the role of bevacizumab and a chemotherapy-free approach, the authors evaluated the combination of bevacizumab, trastuzumab, and paclitaxel (HAT) and the regimen of trastuzumab and bevacizumab (HA) with the addition of paclitaxel after progression (HA-HAT) as first-line treatment for patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer. METHODS: In a noncomparative phase 2 trial, patients were randomized between HAT and HA-HAT. The primary endpoint was the progression-free rate at 1 year (1-year PFR). In the HA-HAT group, progression-free survival (PFS) was separately established for HA (PFS1) and HAT (PFS2). RESULTS: Eighty-four patients received HAT (n = 39) or HA-HAT (n = 45). The 1-year PFR was 74.4% (95% confidence interval [CI], 61.8%-89.4%) and 62.2% (95% CI, 49.6%-89.4%) in the HAT and HA-HAT arms, respectively. The median PFS was 19.8 months (95% CI, 14.9-25.6 months) in the HAT arm and 19.6 months (95% CI, 12.0-32.0 months) in the HA-HAT arm. In the HA-HAT arm, the median PFS1 was 10.4 months (95% CI, 6.2-15.0 months), and the median PFS2 was 8.2 months (95% CI, 7.0-12.6 months). The number and severity of adverse events were comparable between the arms. CONCLUSIONS: Both HAT and HA-HAT have promising activity in patients with HER2-positive metastatic breast cancer. In particular, starting with only targeted agents and delaying chemotherapy is worth further exploration.

Background: The current debate on overdiagnosis and overtreatment of screen-detected ductal carcinoma in situ (DCIS) urges the need for prospective studies to address this issue. A substantial number of DCIS lesions will never form a health hazard, particularly if it concerns non-to slow-growing low-grade DCIS. The LORD study aims to evaluate the safety of active surveillance in women with low-risk DCIS. Design: This is a randomised, international multicentre, open-label, phase III non-inferiority trial, led by the Dutch Breast Cancer Research Group (BOOG 2014-04) and the European Organization for Research and Treatment of Cancer (EORTC-BCG 1401). Standard treatment will be compared to active surveillance in 1240 women aged P45 years with asymptomatic, screen-detected, pure low-grade DCIS based on vacuum-assisted biopsies of microcalcifications only. Both study arms will be monitored with annual digital mammography for a period of 10 years. The primary end-point is 10-year ipsilateral invasive breast cancer free percentage. Secondary end-points include patient reported outcomes, diagnostic biopsy rate during follow-up, ipsilateral mastectomy rate and translational research. Feasibility: To explore interest in and feasibility of the LORD study we conducted a survey among EORTC and BOOG centres. A vast majority of EORTC and BOOG responding centres expressed interest in participation in the LORD study. The proposed study design is endorsed by nearly all centres. (C) 2015 The Authors. Published by Elsevier Ltd.

Background Until recently, trastuzumab (H) combined with a taxane was standard first line systemic therapy for patients with Her2 positive metastatic breast cancer (MBC) who are not candidates for endocrine therapy. Clinical studies have shown that bevacizumab (A) enhances the activity of weekly paclitaxel (T), while preclinical data suggest that A can also augment anti-tumor activity of H. Here we report outcome data of a randomized phase II study in Her2 positive MBC on the combination of HAT versus sequential treatment starting with a chemotherapy-free approach with H and A (HA), followed by adding T at progression (HA-HAT). Methods Patients with Her2 positive MBC, eligible for first-line systemic therapy, were randomized (1:1) between HAT (3-weekly H 6 mg/kg (first dose 8/mg/kg) plus A 15 mg/kg both until progression and T 90mg/m2, day 1,8,15 every 4 weeks for a maximum of 6 cycles) and HA-HAT (doses HA were the same as in HAT with T for a maximum of 6 cycles added to HA at progression). Primary endpoint was progression-free survival rate at 1 year after randomization (PFR-1yr). A regimen yielding a PFR-1yr of around 40% was decided to warrant further exploration (p1). A Fleming one-stage design was, therefore, applied to both arms with p2=20%, alpha=0.05 and beta=0.10. Secondary endpoints included PFS, defined as the time from randomization to documented disease progression (PD) or death from any cause after patients had received HAT. In addition for the HA-HAT group, a PFS1 and PFS2 was established. PFS1 was defined as the time from randomization to PD or death from any cause, PFS2 as the time from starting treatment with HAT to PD or death from any cause. Results Between April 2009 and September 2013, 84 patients were randomized, 39 to HAT and 45 to HA-HAT. Baseline characteristics were similar for both arms: mean age 55 years (range 29-80 years), prior adjuvant chemotherapy in 35% and hormone receptor positive disease in 63%. The primary endpoint was met in both arms. At a median follow-up of 22 months, 26 patients in the HAT arm had progressed of whom 14 had died. The median PFS for the HAT arm was 19.4 months (95% confidence interval (CI) 14.6-25.2). In the HA-HAT arm 23 patients progressed under HA of whom 3 still have no 2nd progression after adding T. Eleven patients of the HA-HAT arm died of whom 2 due to toxicity (1 sigmoid perforation, 1 pneumonia). The median PFS1 was 14.9 months (95% CI 10.9-NA) The median PFS2 was 8.2 months (95% CI 5.9-NA). Overall PFS in the HA-HAT arm was 22.6 months (95% CI 15.4-NA). Grade 3 or higher toxicity was 3 times more often seen during treatment including T. More detailed information regarding toxicity will be shown at the meeting. Conclusion Both HAT and HA-HAT are active regimens in Her2 positive MBC. In particular the sequential approach with starting monoclonal antibodies only, yielding a median PFS of more than 1 year and a relatively mild toxicity profile, and adding chemotherapy at progression is worthwhile to be further explored. Financial support Roche Netherlands. Citation Format: Jan C Drooger, Harm van Tinteren, Steffen M de Groot, Albert J ten Tije, Hiltje de Graaf, Johanneke EA Portielje, Agnes Jager, Aafke H Honkoop, Sabine C Linn, Judith R Kroep, Frans LG Erdkamp, Paul Hamberg, Joan B Heijns, A Elise van Leeuwen-Stok, Stefan Sleijfer. Results from a randomized phase II study of the Dutch Breast Cancer Research Group (BOOG 2008-03): Concomitant trastuzumab, bevacizumab and paclitaxel (HAT) versus trastuzumab and bevacizumab, followed by trastuzumab, bevacizumab and paclitaxel (HA-HAT) a [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 P4-15-12.

Background The goal in treating patients with ductal carcinoma in situ (DCIS) is to prevent the development of invasive breast cancer (iBC). However, a substantial number of DCIS lesions will never form a health hazard, particularly if it concerns slow-growing, low-grade DCIS. The conventional treatment of low-grade DCIS is similar to that of early-stage iBC, i.e. breast-conserving surgery (BCS) often followed by radiotherapy (RT), or mastectomy, and possibly hormonal therapy (HT). This implies that many women might be unnecessarily going through intensive treatment resulting in a decrease in quality of life and an increase in health care costs, without any survival benefit. Trial Design LORD is a randomized, international, multicenter, phase III non-inferiority trial. Patients will be randomized between active surveillance and standard treatment according to local policy. Active surveillance comprises monitoring by annual mammography and treatment if there is progression to iBC or higher grade DCIS. Standard treatment encompasses BCS only, BCS + RT, or mastectomy, possibly followed by HT, and follow-up by annual mammography. Eligibility criteria • Women ≥49 years • Referral to the hospital solely based on microcalcifications detected by population-based or opportunistic screening mammography • Unilateral, pure DCIS grade I based on multiple vacuum assisted biopsies • No prior history of iBC or DCIS Specific Aims Our aim is to investigate whether active surveillance of low-grade DCIS is as safe as the current standard treatment, and to study the effects on quality of life of these women by saving them from intensive treatment. The primary end-point is time to ipsilateral iBC (iiBC). Secondary end-points include rate of iBC at final pathology after standard treatment, radical intervention rate, and biopsy rate during follow-up. Tissue will be collected for genomic profiling and proteomics to detect iBC risk patterns in low-grade DCIS. Furthermore we aim to develop an online informational aid for clinicians and patients to facilitate the dissemination and understanding of information on low-grade DCIS and its treatment. Statistical Methods We apply a special type of non-inferiority design, where the alternative hypothesis corresponds to "minor inferiority". We assume that the iiBC-free rate in the standard arm at 5 years equals 97.6%. The hazard ratio under the null hypothesis is 3.4 and the hazard ratio under the alternative hypothesis is 2.1, corresponding to iiBC-free rates in the experimental arm of 92.0% and 95.0% respectively. With a one-sided log-rank test for non-inferiority with α=0.05 and β=0.2, 124 events are needed for which 1842 low-grade DCIS patients need to be randomized during an accrual period of 5.5 years, and the accrual period will be followed by a further follow-up period of 7.5 years. Present Accrual and Target accrual The LORD trial is endorsed by the Dutch Breast Cancer Research Group (BOOG 2014-04) and the European Organisation for Research and Treatment of Cancer (EORTC 1401). Participating sites will be identified mid-2014. Patient accrual is expected to start early 2015. Citation Format: Lotte E Elshof, Konstantinos Tryfonidis, Leen Slaets, A Elise van Leeuwen-Stok, Nicolas Dif, Victoria P Skinner, Claudette E Loo, Gonneke Warnars, Eveline Bleiker, Ruud M Pijnappel, Nina Bijker, Emiel JTh Rutgers, Jelle Wesseling. The LORD trial: A randomized, non-inferiority trial, between active surveillance versus standard treatment in patients with low risk ductal carcinoma in situ [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 OT3-6-01.

To explore the role of bevacizumab and a chemotherapy-free approach, the authors evaluated the combination of bevacizumab, trastuzumab, and paclitaxel (HAT) and the regimen of trastuzumab and bevacizumab (HA) with the addition of paclitaxel after progression (HA-HAT) as first-line treatment for patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer.In a noncomparative phase 2 trial, patients were randomized between HAT and HA-HAT. The primary endpoint was the progression-free rate at 1 year (1-year PFR). In the HA-HAT group, progression-free survival (PFS) was separately established for HA (PFS1) and HAT (PFS2).Eighty-four patients received HAT (n = 39) or HA-HAT (n = 45). The 1-year PFR was 74.4% (95% confidence interval [CI], 61.8%-89.4%) and 62.2% (95% CI, 49.6%-89.4%) in the HAT and HA-HAT arms, respectively. The median PFS was 19.8 months (95% CI, 14.9-25.6 months) in the HAT arm and 19.6 months (95% CI, 12.0-32.0 months) in the HA-HAT arm. In the HA-HAT arm, the median PFS1 was 10.4 months (95% CI, 6.2-15.0 months), and the median PFS2 was 8.2 months (95% CI, 7.0-12.6 months). The number and severity of adverse events were comparable between the arms.Both HAT and HA-HAT have promising activity in patients with HER2-positive metastatic breast cancer. In particular, starting with only targeted agents and delaying chemotherapy is worth further exploration. Cancer 2016;122:2961-2970. © 2016 American Cancer Society.

The introduction of population-based breast cancer screening and implementation of digital mammography have led to an increased incidence of ductal carcinoma in situ (DCIS) without a decrease in the incidence of advanced breast cancer. This suggests DCIS overdiagnosis exists. We hypothesize that asymptomatic, low-grade DCIS can safely be managed by active surveillance. If progression to invasive breast cancer would still occur, this will be low-grade and hormone receptor positive with excellent survival rates. Also, breast-conserving treatment will still be an option, if no prior radiotherapy has been applied. It also may save many low-grade DCIS patients from intensive treatment. We will compare active surveillance with conventional treatment, being either wide local excision (WLE) only, WLE plus radiotherapy or mastectomy, possibly followed by hormonal therapy for primary low-grade DCIS, detected by calcifications only, in a phase III, open-label, non-inferiority, multi-center, randomized clinical trial legally supported by the Breast Cancer Group of the European Organisation for the Research and Treatment of Cancer (EORTC-1401-BCG). The Dutch Centers are coordinated by the BOOG Study Center (BOOG 2014-04). Randomization will be 1:1 in to one of the following arms: active surveillance or standard treatment per local policy. In total, 1240 women (≥ 45 years) with asymptomatic, pure, low-grade DCIS, based on vacuum-assisted biopsies of calcifications as detected by population-based or opportunistic screening, without prior breast cancer, will be included. Assuming 25% of randomized women qualified to enroll in the study will drop out or will be excluded from per protocol population, at least 1,240 women need to be randomized to obtain the 930 patients required for the evaluation of the primary endpoint. The same follow-up scheme will be applied in both study arms, i.e. annual mammography for a period of 10 years. The primary end-point is ipsilateral invasive breast tumor-free rate at 10 years. Secondary end-points are among others: overall survival, breast cancer-specific survival, mastectomy rate and patient reported outcomes. Accrual has started in January 2017. Acknowledgements: This trial is funded by Pink Ribbon Netherlands, the Dutch Cancer Society and Dutch Cancer Society/Alpe d’HuZes. Citation Format: Jelle Wesseling, Frederieke van Duijnhoven, Konstantinos Tryfonidis, Aleksandra Peric, Elise van Leeuwen-Stok, Nina Bijker, Lotte Elshof, Emiel Rutgers. Standard therapy versus active surveillance for low grade DCIS: the LORD trial [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr CT137. doi:10.1158/1538-7445.AM2017-CT137

// Annelot G.J. van Rossum 1 , Marleen Kok 2, 3 , Danielle McCool 1 , Mark Opdam 1 , Nienke C. Miltenburg 4 , Ingrid A.M. Mandjes 5 , Elise van Leeuwen-Stok 6 , Alex L.T. Imholz 7 , Johanneke E.A. Portielje 8 , Monique M.E.M. Bos 9 , Aart van Bochove 10 , Erik van Werkhoven 11 , Marjanka K. Schmidt 1 , Hendrika M. Oosterkamp 12, * and Sabine C. Linn 1, 3, 13, * 1 Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands 2 Division of Immunology, Netherlands Cancer Institute, Amsterdam, The Netherlands 3 Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands 4 Department of Neurology, Medical Center Slotervaart, Amsterdam, The Netherlands 5 Data Center, Netherlands Cancer Institute, Amsterdam, The Netherlands 6 Dutch Breast Cancer Research Group, BOOG Study Center, Amsterdam, The Netherlands 7 Department of Medical Oncology, Deventer Ziekenhuis, Deventer, The Netherlands 8 Department of Medical Oncology, HagaZiekenhuis, The Hague, The Netherlands 9 Department of Medical Oncology, Reinier de Graaf Groep, Delft, The Netherlands 10 Department of Medical Oncology, Zaans Medisch Centrum, Zaandam, The Netherlands 11 Biometrics Division, Netherlands Cancer Institute, Amsterdam, The Netherlands 12 Department of Medical Oncology, Haaglanden Medisch Centrum, The Hague, The Netherlands 13 Department of Pathology, University Medical Center, Utrecht, The Netherlands * These authors contributed equally to this work Correspondence to: Sabine C. Linn, email: s.linn@nki.nl Keywords: replication; single nucleotide polymorphisms; association; toxicity; chemotherapy Received: April 13, 2017 Accepted: October 27, 2017 Published: November 27, 2017 ABSTRACT Introduction: Although pharmacogenomics has evolved substantially, a predictive test for chemotherapy toxicity is still lacking. We compared the toxicity of adjuvant dose-dense doxorubicin-cyclophosphamide (ddAC) and docetaxel-doxorubicin-cyclophosphamide (TAC) in a randomized multicenter phase III trial and replicated previously reported associations between genotypes and toxicity. Results: 646 patients (97%) were evaluable for toxicity (grade 2 and higher). Whereas AN was more frequent after ddAC ( P < 0.001), TAC treated patients more often had PNP ( P < 0.001). We could replicate 2 previously reported associations: TECTA (rs1829; OR 4.18, 95% CI 1.84-9.51, P = 0.001) with PNP, and GSTP1 (rs1138272; OR 2.04, 95% CI 1.13-3.68, P = 0.018) with PNP. Materials and methods: Patients with pT1-3, pN0-3 breast cancer were randomized between six cycles A60C600 every 2 weeks or T75A50C500 every 3 weeks. Associations of 13 previously reported single nucleotide polymorphisms (SNPs) with the most frequent toxicities: anemia (AN), febrile neutropenia (FN) and peripheral neuropathy (PNP) were analyzed using logistic regression models. Conclusions: In this independent replication, we could replicate an association between 2 out of 13 SNPs and chemotherapy toxicities. These results warrant further validation in order to enable tailored treatment for breast cancer patients.

1028 Background: The role of bisphosphonates when added to the neoadjuvant treatment of BC in enhancing the efficacy of therapy is still unknown. Methods: NEOZOTAC is a national, multicenter, randomized study comparing the efficacy of TAC (docetaxel, Adriamycin and cyclophosphamide i.v.) CT followed by G-CSF on day 2 with or without ZA 4 mg i.v. ,q 3 weeks in patients (pts) with stage II/III, measurable, HER2-negative BC and absence of prior bisphosphonate usage. The primary endpoint is the pathologic complete response (pCR) rate in the resection specimen and positive lymph nodes. 228 pts are needed to show an improvement of the pCR rates from 17% to 34% in the experimental arm using a 5% significance level based on the two-sided Fisher’s exact test with a power of 80%. Randomization was done by using the Pocock’s minimisation technique stratified by cT, cN and estrogen receptor status. pCR rate was analyzed using the Cochran-Mantel-Haenszel test, adjusting for the stratification factors. Analysis was based on intent-to-treat. An unplanned subgroup analysis of postmenopausal women (PMW; FSH >20 and estradiol