1. Neo-Adjuvant Systemic Treatment: Current Modalities Luc Y. Dirix Medical Oncology Oncologisch Centrum GvA, Antwerp. October 14, 2006

2. Neo-Adjuvant or Pre-operative Systemic Chemotherapy in Patients with Primary Operable Breast Cancer (POBC) To improve surgical options –Reduce size Increase BCS Decrease local recurrences To obtain improved long-term survival –Systemic therapy prior to S S releases and/or stimulates TC CT more early To obtain information on response –In-vivo drug sensitivity test To answer biological questions

3. Pre-operative Systemic Therapy (PST) in Patients with Primary Operable Breast Cancer (POBC) A)Endpoints B)Types of PST C) Surgical Considerations

4. Pre-operative Systemic Therapy (PST) in Patients with Primary Operable Breast Cancer (POBC) Endpoints Pathological assessment MRI - PET CTC - CEC DTC

5. Neo-Adjuvant Chemotherapy and pCR NSABP definition pCR –No residual invasive tumor in the breast –DCIS allowed –LNN Stringent definition of pCR –No invasive tumor in breast –No DCIS allowed –LNN are free Methodological issues

6. PST in POBC : Definitions of Pathological Response

7. PST in POBC : Role of MRI DCE-MRI accurately predicts response early on Relation tumor diameter on pathology and DCE- MRI 0.824 DCE-MRI in is superior in predicting pCR (PE, Mammography, US) DCE-MRI over- and underestimates pCR DCE-MRI effect of bevacizumab Is MRI defined CR a prognostic factor ? ACRIN,CALGB Intergroup 49808 : utility of MRI (www.acrin.org, current protocol section)www.acrin.org

8. PST in POBC : Role of F 18 FDG PET Early decrease in SUV in responders Reliable in defining non-responders or PD SUVp RR n = 50 a RR -88% threshold pCR and pPR Sensitivity 100%, Specificity 56.5% AUC 0.788 PET is able to differentiate pathological responders after 1-2 cycles CT with an accuracy of 91%, a sensitivity of 100% PET is a poor discriminator of pCR

9. PST in POBC : Role of DTC/CTC CTC and PST Pachman et al., n=30 epi-based PST 100% CEC 600-273,150 cells/ml R 2 = 0.97 change TV and log fold decrease CEC REMAGUS 02 RPII study (PASCO 2006) CTC CellSearch, n=60 1CTC in 15/56, >2CTC 8/56 CEC and EPC and PST Füstenberger et al., n=10 Decrease in CEnC correlated with PST Increase in VEGF,EPC No data on DTC in BM and PST

10. Pre-operative Systemic Therapy (PST) in Patients with Primary Operable Breast Cancer (POBC) A) Types of PST –Chemotherapy Anthracycline-based Taxane based Anti-HER2 Anti-VEGF –Endocrine therapy –Predictors of efficacy

11. Randomized Clinical Trials on PST with an Anthracycline Based Regimen Study N Regimen BCT pCR DFSOS% NSABP-181523ACx46813nono EORTC698FECx4304nono Scholl390FACx482NAnono Mauriac 272EVM-MTV62-nono

13. Randomized Clinical Trials on PST with a Taxane Based Regimen StudyN Regimen %pCR NASBP-272411ACx4-Dx426 ACx4 14 ECTO451APaclx4-CMFx423 GEPARDUO913ACx4-Tx422 2wADx411 ACCOG363ACx624 ADx621 MDACC2583wTx4-FACx414 wTx12-FACx429 AGO6312wEx3-2wTx318 Epacli x 410

14. NSABP B-27 IIIIII Operable Breast Cancer AC x 4 Tam x 5y SurgeryDocetaxel x 4 Surgery Docetaxel x 4 AC x 4 Tam x 5y AC x 4 Tam x 5y

15. NSABP B-27: pCR in Breast % *p<0.001 for test of heterogeneity across groups n=764 n=767 12.8%* 26.1%* 14.3%* n=775

16. NSABP B-27 Overall Survival % Surviving Years after Surgery TRTNDeaths Group I801150 Group II803143HR=0.94p=0.57 Group III799163HR=1.07p=0.53

17. NSABP B-27: RFS % Relapse-free Years after Surgery TRTNEvents Group I801247 Group II803210HR=0.81p=0.03 Group III799230HR=0.91p=0.32

18. NSABP B-27: DFS pCR vs. non-pCR Patients % Disease-free Years after Surgery TRTNEvents Non pCR1899638 pCR40971 HR=0.45 p<0.0001

19. NSABP B-27: OS pCR vs. non- pCR Patients % Surviving Years after Surgery TRTNDeaths Non pCR1899396 pCR40931 HR=0.33 p<0.0001 3-31-04

20. PST with Single Agent Trastuzumab Gennari et al. Clin Cancer Res, 5050, 2004 11 patients HER2+ POBC Trastuzumab 4mg/kg, 2mg/kg/we S by day 21-28 1 cCR and 7cPR No difference in TC proliferation All tumors showed ly infiltration TR - ADCC

21. PST with Trastuzumab and Chemotherapy AuthorNRegimenpCRcRR Burstein 200340PH18%75% Harris 200328NH-93% Bines 200333TH12%95% Wenzel 200418TEHw-86 % Buzdar 200523P-FEC+H65%87% Hurley 200530TCH13% Coudert 200633TH47%96%

22. PST with Trastuzumab: RCT 42 pts HER-2 + BC (4T1,28T2,9T31T4) 4xPac 225mg/sqm/24h, 4xFEC(d1,4)+/-H pCR = in breast and LNN = no invasive T 2 pts FISH negative pCR 26.3% vs 65,2% (43%-84%) pCR irrespective of ER status 10% decrease in LVEF in five and seven

23. Wedam, S. B. et al. J Clin Oncol; 24:769-777 2006 DCE-MRI and clinical responses in a patient with partial response

24. Wedam, S. B. et al. J Clin Oncol; 24:769-777 2006 ( p-VEGFR2) by immunohistochemistry

25. PST : Effect of Bevacizumab

26. Candidate Single Gene Predictive Markers : HR

27. Neo-Adjuvant Chemotherapy and pCR

30. Hess, K. R. et al. J Clin Oncol; 24:4236-4244 2006 Learning curve for Diagonal Linear Discriminant Analysis-30 classifier

31. Mean area above the receiver operating characteristic (ROC) curves plotted against the number of top genes included in the classifiers

32. Hess, K. R. et al. J Clin Oncol; 24:4236-4244 2006 ROC curves of three distinct pathologic complete response prediction models

33. Genome Wide Expression Profiling: The Ultimate Predictor ?

34. PST with Chemotherapy & BCS BCT after AT -CMF (ECTO) BCSLNN- S-Ax4-CMFx438%35% ATx4-CMFx4-S61%71%

35. PST in Patients with POBC Breast conserving treatment is feasible and safe. Pre-treatment assessment (SLN) is advisable. pCR is possible both in breast and LNN. Surgery is not be omitted even in cCR. A taxane-anthracycline combination seems optimal. Sequential therapy seems preferable. Addition of Herceptin increases pCR if HER-2 ampl. Optimal duration of PST is unclear. PET and DCE-MRI allow for recognition of non- responders. Is pCR a surrogate for “activity” on CTC-DTC? pCR in nodes remains a prognostic factor pCR predicts survival (most convincingly if ER-)