Background: In high-risk hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) early breast cancer (EBC), nanoparticle albumin-bound (nab)-paclitaxel showed promising efficacy versus solvent-based (sb)-paclitaxel in neoadjuvant trials; however, optimal patient and therapy selection remains a topic of ongoing research. Here, we investigate the potential of Oncotype DX & REG; recurrence score (RS) and endocrine therapy (ET) response (low post-endocrine Ki67) for therapy selection.Patients and methods: Within the WSG-ADAPT trial (NCT01779206), high-risk HR+/HER2- EBC patients were randomized to (neo)adjuvant 4x sb-paclitaxel 175 mg/m2 q2w or 8x nab-paclitaxel 125 mg/m2 q1w, followed by 4x epirubicin + cyclophosphamide (90 mg + 600 mg) q2w; inclusion criteria: (i) cN0-1, RS 12-25, and post-ET Ki67 >10%; (ii) cN0-1 with RS >25. Patients with cN2-3 or (G3, baseline Ki67 >40%, and tumor size >1 cm) were allowed to be included without RS and/or ET response testing. Associations of key factors with pathological complete response (pCR) (primary) and survival (secondary) endpoints were analyzed using statistical mediation and moderation models.Results: Eight hundred and sixty-four patients received neoadjuvant nab-paclitaxel (n = 437) or sb-paclitaxel (n = 427); nab-paclitaxel was superior for pCR (20.8% versus 12.9%, P = 0.002). pCR was higher for RS >25 versus RS <25 (16.0% versus 8.4%, P = 0.021) and for ET non-response versus ET response (15.1% versus 6.0%, P = 0.027); no factors were predictive for the relative efficacy of nab-paclitaxel versus sb-paclitaxel. Patients with pCR had longer distant disease-free survival [dDFS; hazard ratio 0.42, 95% confidence interval (CI) 0.20-0.91, P = 0.024]. Despite favorable prognostic association of RS >25 versus RS <25 with pCR (odds ratio 3.11, 95% CI 1.71-5.63, P < 0.001), higher RS was unfavorably associated with dDFS (hazard ratio 1.03, 95% CI 1.01-1.05, P = 0.010).Conclusions: In high-risk HR+/HER2- EBC, neoadjuvant nab-paclitaxel q1w appears superior to sb-paclitaxel q2w regarding pCR. Combining RS and ET response assessment appears to select patients with highest pCR rates. The disadvantage of higher RS for dDFS is reduced in patients with pCR. These are the first results from a large neoadjuvant randomized trial supporting the use of RS to help select patients for neoadjuvant chemotherapy in high-risk HR+/HER2- EBC.

Abstract Background: A number of prognostic signatures have been developed for the prediction of breast cancer recurrence in the past decade. We have developed two signatures (Clinical Treatment Score (CTS), four immunohistochemical markers (IHC4)) and validated four prognostic signatures (Oncotype Dx Recurrence Score (RS), PAM50-based Prosigna (ROR), Breast Cancer Index (BCI), and EndoPredict (EPclin)) in the TransATAC cohort. Here, we compare the prognostic performance of these six signatures for distant recurrence (DR) in years 0-10, and specifically in years 5-10 after treatment cessation. Methods: 1231 postmenopausal women with hormone receptor positive and HER2-negative breast cancer had at least one test performed. Of these, 818 women had data on all six signatures available. IHC4, RS and BCI (linear) are molecular only signatures whereas CTS, ROR and EPclin include clinicopathological factors. The primary endpoint was DR and the primary objective was to compare the prognostic value of the six signatures in terms of DR for years 0-10, 0-5, and 5-10. Secondary objectives included the comparison of the prognostic performance for node-negative and node-positive patients separately and the additional prognostic performance of each signature to the others. Likelihood ratio statistics (LR-χ2) were used to assess the prognostic information of each signature alone or in combination with other signatures. Results: Median follow-up for this analysis was 9.94 years (IQR 8.01-10.09) and a total of 126 DR were recorded. 818 women with HER2-negative disease for whom data of all six signatures were available were included in this analysis. For all patients, CTS and EPclin were the most prognostic signatures in years 0-10 (CTS: LR-χ2=124.9; EPclin: LR-χ2=116.2) and years 5-10 (CTS: LR-χ2=59.6; EPclin: LR-χ2=56.8) in the univariate analysis. The other four signatures performed similarly well in years 0-5, but of those only BCI and ROR provided substantial prognostic information in years 5-10 (BCI: LR-χ2=25.3; ROR: LR-χ2=43.8). In multivariate analyses comparing the added information of the molecular signatures over CTS, IHC4 and BCI provided the most information (IHC4: ΔLR-χ2=19.0; BCI: ΔLR-χ2=19.8). In node-negative patients (72.3%), the ROR showed the most prognostic value in years 0-10 (LR-χ2=48.6) and years 5-10 (LR-χ2=31.3) whereas the RS was least prognostic in this patient group. For patients with node-positive disease (27.7%), the CTS and EPclin were the most prognostic and the other four signatures provided much less prognostic information for this patient population (data not shown). Conclusion: Overall, the CTS and EPclin were the most prognostic signatures for DR and also added significant prognostic value to the other scores in women with HER2-negative disease, primarily due to the incorporation of nodal status in these signatures. For women with node-negative disease, the ROR, BCI, and EPclin signatures provided most prognostic value whereas for those with positive nodes CTS and EPclin were most prognostic. Our analyses showed that the inclusion of clinic-pathological factors into gene signatures is highly important for deriving an accurate prognostic assessment, particularly in node-positive patients. Citation Format: Sestak I, Buus R, Cuzick J, Dubsky P, Kronenwett R, Ferree S, Sgroi D, Schnabel C, Baehner R, Mallon E, Dowsett M. Comprehensive comparison of prognostic signatures for breast cancer in TransATAC [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr S6-05.

Abstract Background: DCIS patients need better tools to align the aggressiveness of treatment with the aggressiveness of their disease. The DCIS Score (DS) was validated as a predictor of ipsilateral breast recurrence (IBR; DCIS or invasive) in 327 E5194 patients treated by breast-conserving surgery (BCS) without radiation (RT) (Solin,2013). This Ontario population based DCIS study of 3335 women with DCIS from 1994 to 2003 (Rakovitch,2013) was conducted to test the DCIS Score as a predictor of recurrence risk in patients treated with BCS alone and in patients treated with BCS+RT. Methods: REMARK guidelines were followed. Breast pathologists centrally reviewed all H&E slides. The Oncotype DX DCIS Score was obtained by standardized quantitative RT-PCR using fixed paraffin embedded tumor. The pre-specified primary objective was to determine the relationship (hazard ratio (HR)/50 units) between the risk of an IBR and the continuous DS (using Cox models) in patients treated with BCS alone with ER+ tumors and clear margins (CM, no ink on tumor). Results: Tumor blocks were collected for 1569 patients (47% of parent cohort); 718 received BCS without RT (N=571 with CM) and 846 received BCS+RT (N=689 with CM). Median follow-up was 9.4 years. Among 1260 pts with CM, 100 pts treated with BCS alone had an IBR (DCIS, N=44; invasive, N=57); 86 pts treated with BCS+RT had an IBR (DCIS, N=32; invasive, N=55). In the primary analysis, among 571 patients treated by BCS alone with CM the continuous DS was significantly associated with IBR in ER+ patients (HR 2.26; 95%CI 1.41,3.59; P=0.001) and in all patients (HR 2.15; 95%CI 1.43,3.22; P=<0.001). The DS was also associated with invasive IBR (HR 1.78; 95%CI 1.03,3.05; P=0.04); similar but non-significant results were noted in the ER+ subgroup (P=0.08). Among 689 pts with CM treated by BCS+RT, the DS was associated with IBR (HR 2.78; 95%CI 1.77,4.41; P=<0.001). There was no interaction between the DS and RT (P=0.40). In multivariable analysis for IBR in CM cases, the HR/50 units for the DCIS Score among patients treated with BCS alone was 1.80(95%CI 1.17,2.74; P=0.008) and 2.86(95%CI 1.79,4.62, P=<0.001) for those treated with BCS+RT adjusting for multifocality, tumor size and age. Conclusions: DCIS Score quantifies recurrence risk for DCIS patients treated by BCS with or without RT. Integrating the DCIS Score with established risk factors, such as multifocality, age, and tumor size, can help identify DCIS patients treated with BCS alone with low 10 year risk (<10%) of recurrence and those who still have high 10 year risk of recurrence despite RT who may be candidates for more aggressive treatment. BCS Alone, CMBCS with RT, CMDCIS Score Risk Group10-Yr Kaplan-Meier IBR Rate (95%CI)10-Yr Kaplan-Meier IBR Rate (95%CI) All patients (N=571)Unifocal DCIS (N=457)All patients (N=689)Multifocal DCIS (N=177)Low (<39)12.7% (9.5%,16.9%) N=3559.7% (6.8%,13.8%) N=2987.5% (4.9%,11.2%) N=3329.8% (4.6%,20.1%) N=91Int (39-54)33.0% (23.6%,44.8%) N=9527.1% (17.7%,40.2%) N=7213.6% (8.6%,21.2%) N=15520.6% (10.3%,38.7%) N=37High (>55)27.8% (20.0%,37.8%) N=12127.0% (18.2%,38.9%) N=8720.5% (15.1%,27.5%) N=20233.3% (21.9%,48.5%) N=49Log rank P-value<0.001<0.001<0.001<0.001 Citation Format: Eileen Rakovitch, Sharon Nofech-Mozes, Wedad Hanna, Frederick L Baehner, Refik Saskin, Steven M Butler, Alan Tuck, Sandip Sengupta, Leela Elavathil, Prashant A Jani, Michel Bonin, Martin C Chang, Elzbieta Slodkowska, Joseph M Anderson, Farid Jamshidian, Diana B Cherbavaz, Steven Shak, Lawerence Paszat. A large prospectively-designed study of the DCIS score: Predicting recurrence risk after local excision for ductal carcinoma in situ patients with and without irradiation [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 S5-04.

Abstract Background: Prognostically distinct subtypes of BC defined by gene expression include luminal A, luminal B, HER2-enriched, basal-like and normal breast-like tumors. Luminal subtypes express estrogen receptor (ER)-related genes; patients with luminal B tumors have a poorer prognosis and higher proliferation compared to those with luminal A tumors. For HR+ disease, accessible and affordable surrogates for identification of luminal subtypes may aid in selecting appropriate systemic therapy and assessing eligibility to novel agent clinical trials targeted toward specific biology. Recent studies support use of Ki67 positivity by immunohistochemistry (IHC) with a cut point of 15%, along with standard receptors, as an appropriate surrogate for luminal B. Methods: 116 I-SPY 1 TRIAL patients with intrinsic subtype assignments had Ki-67 IHC-stained pre-treatment whole tissue sections available for digital image quantification. The percentage of Ki67-positive nuclei was quantified using the Aperio Nuclear V9 (cell quantification) algorithm. Intrinsic subtype was previously determined by standard methods applied to Agilent 44K gene expression data. We selected the 49 patients with HR+/HER2- tumors for this analysis. Ki67 positivity was categorized into two groups: low (<15%) and high (≥15%). Association between intrinsic subtype and Ki67 was determined using Fisher's exact method. Results: The 49 pts with HR+/HER2- disease were classified by gene expression into intrinsic subtypes as follows: 26 (53%) luminal A, 15 (31%) luminal B, 2 (4%) HER2-enriched, 6 (12%) basal, and 0 normal. The fraction of Ki67 positive cells ranged from 0.28% to 86.8%, with a mean of 20.5%. The mean Ki67 positive fraction was 13% and 24% in LumA and LumB subgroups, respectively. Using the 15% cutoff, Ki67 was low in 25 (51%) and high in 24 (49%) cases. The majority of luminal A tumors have low Ki67 (17/26, 65%) and luminal A subtype was associated with Ki67 (p = 0.047). However, nearly a third of tumors with low Ki67 are not luminal A (8/25, 32%). High Ki67 tumors were distributed among luminal A (18%), luminal B (18%), basal (10.2%), and HER2-enriched (2%) subtypes; luminal B subtype was not associated with high Ki67 (p = 0.36) in this cohort. Conclusion: In this high-risk population, 16% of HR+/HER2- tumors were either basal or HER2-enriched by intrinsic subtyping. Low Ki67 (<15%) was associated with luminal A; this did not exclude other subtypes. In this well characterized group, high Ki67 (≥15%) in combination with ER status did not serve as a surrogate for luminal B subtype. These results suggest that intrinsic subtype classifications reflect information beyond that captured by hormone receptor status combined with Ki67 positivity. This research was partially supported by NIH CA31946 and CA33601. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-02-06.

Goals: Both, the Recurrence Score (RS) and uPA/PAI-1 are guidelinerecommended biomarkers for adjuvant chemotherapy decision in early breast cancer (BC).Central grade, molecular classification provides prognostic information in HR+ disease.Here, we present the first preplanned WSG-Plan B trial correlation analysis of RS with central grade, nodal status, uPA/PAI-1, and luminal A/B subtypes by protein expression.Methods: Plan B trial evaluates anthracyline-free adjuvant CHT 6×TC vs. 4×EC-4×DOC in HER2-BC.Pts with low RS 11 and 0-3 positive LN are treated with hormonal therapy alone.uPA/PAI-1 as measured by ELISA is obtained as an optional risk factor.Tumor blocks are prospectively evaluated by central pathology for grade, histology, and Ki-67.Results: By November 2010, 2094 patients have been registered into the WSG Plan B trial.RS results are available in 1534 patients with HR+ BC.No significant correlation between RS and nodal status could be observed.Within the Ki-67 pilot project, 298 patients were evaluated; 131 patients within the uPA/PAI-1 sub-project were available.When considered as continuous variables, RS was weakly positively correlated with uPA (rs = 0.18, p = 0.04) and with PAI-1 (rs = 0.23, p = 0.01).When considered as risk categories, there was a weak concordance between RS and uPA/PAI-1, using several RS cut-offs (11/18 and 25/30).We observed a strong correlation between central grade and RS (r s = 0.331, p < 0.001), and Ki-67 as continuous variable (median 20) (r = 0.571, p < 0.001).Assignment of high risk was strongly concordant between uPA/PAI-1 and RS as well as between luminal B subtype and RS, but there was substantial discordance within the low and intermediate risk groups by RS.There is a significant correlation only between PAI-1 and Ki-67 expression (rs = 0.41, p = 0.005). Conclusion:For the first time, risk groups in primary breast cancer according to RS, luminal subtypes, central grade, and uPA/PAI-1 have been prospectively compared.These preliminary data of the prospective Plan B trial show that only the high, but not low and intermediate risk groups by all markers seem to be highly concordant.

Background: Despite progress in adjuvant breast cancer (BC) treatment, overtreatment due to decisions based on conventional prognostic factors (lymph nodes (LN), grade, tumor size) alone remains an important clinical problem. Recurrence Score®, RS is validated using pre-specified analyses, genes, cutt-offs in several randomized patient collectives as a potent prognostic and predictive marker in HR positive BC. Here, we present the first WSG-Plan B trial preplanned correlation analysis of central grade, nodal status, RS, and luminal A/B subtypes. Material and Methods: The West German Study Group (WSG) Plan B trial (planned n=2,448) is a randomized Phase-III-trial evaluating anthracyline-free adjuvant chemotherapy (Cht) (6x TC) vs. standard 4xEC-4xDOC in high-risk N0 and N+ HER2-negative BC. In HR+ BC with 0-3 LN, RS is the decision criterion for (>11) or against (≥11) Cht randomization. Tumor blocks are prospectively evaluated by a central pathologist for grade, histology and Ki-67. In HR+ disease, molecular subtypes (luminal A vs. B) are grouped using a Ki-67 cut-off of 13.25% (Cheang et al, JNCI 2009) and 20% (Penault-Llorca et al JCO 2009). Exploratory analysis with Elston-Ellis central grade and Ki-67 based (mitosis measured by Ki-67) grade will be performed. Results: As of June 2010, 1375 patients in 96 centers have been registered and 1067 randomized into Plan B. In 298 patients, RS results and clinical-pathological characteristics were available. In 266 patients complete information on all factors was available (132 N0, 134 N+). RS groups using the pre-specified trial cut-offs of 0-11, 12-25 and 30) were 48%, 38%, 14%. Central grade 1, 2, or 3 was observed in 4%, 50%, and 46% of cases. We observed a modest (Spearman) correlation between central grade and RS (e.g 83.8% of G3 tumors with RS >25, r s =0.331, P s =0.34, P s =0.438, P 25), and guideline-recommended 30 (see table 1).Discussion: For the first time, we demonstrate a modest but significant correlation between centrally assed tumor grade, molecular classes by IHC Ki-67 cutt offs, and RS, particularly in the high RS group. However, our data also indicate that there is substantial discordance between the methods and thus an urgent need for optimzing risk-stratification classifiers. Table 1. Association of RS and molecular subtypes Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-10-12.

Organ transplant recipients have an increased tumor incidence owing to their immunocompromised state. The origin of such tumors, whether donor or recipient, will have a clinical impact on decision-making concerning immunosuppressive therapy, retransplantation, and for recipients of other organs from the same donors. We report molecular cytogenetic determination of donor origin in 2 cases of small-cell neuroendocrine carcinoma developing in sex-mismatched transplant recipients (kidney and liver). Fluorescence in situ hybridization (FISH) analysis was performed on liver core needle biopsy material from the liver transplant patient and on liver fine needle aspiration cytopreparations from the kidney transplant patient. The results for the liver transplant patient were confirmed with microsatellite allelic analysis and with comparative genomic hybridization. In both cases, FISH showed the presence of only X chromosomes within the tumor cells, indicating the donor origin of the neoplasms. FISH is an excellent method to determine neoplastic origin in sex-mismatched transplant patients. HUM PATHOL 31:1425-1429.

Magnetic resonance imaging has been used to evaluate 10 children with lymphomas and was able to identify disease in all 10 cases and monitor response to therapy in all three patients with follow-up studies. It could not distinguish between the different histological types of lymphoma. The image intensity of a diseased spleen in one case was different from that of five other normal spleens in six children with Hodgkins disease. Magnetic resonance imaging compared well with computed tomography and it was especially good at identifying blood vessels.

Seven children underwent magnetic resonance imaging (MRI) of the bone marrow: results showed that it is technically feasible to obtain good MR images of marrow in children. MR has detected abnormality in the bone marrow of a child who had metastatic neuroblastoma. The extent of abnormality in the femur correlated well with findings of a bone marrow isotope scan. In one child who had idiopathic aplastic anemia, diseased marrow could not be distinguished from normal marrow on MR images. MRI identified abnormality of the marrow in osteogenic sarcoma, and demonstrated change in response to chemotherapy. It displayed marrow spread of tumor as well as CT. MRI showed marrow abnormality in four children who had leukemia.