Clinical and genomic analysis of a randomised phase II study evaluating anastrozole and fulvestrant in postmenopausal patients treated for large operable or locally advanced hormone-receptor-positive breast cancer

Nathalie Quenel-Tueux, Marc Debled, Justine Rudewicz, Gaetan MacGrogan, Marina Pulido, Louis Mauriac, Florence Dalenc, Thomas Bachelot, Barbara Lortal, Christelle Breton-Callu, Nicolas Madranges, Christine Tunon de Lara, Marion Fournier, Hervé Bonnefoi, Hayssam Soueidan, Macha Nikolski, Audrey Gros, Catherine Daly, Henry Wood, Pamela Rabbitts, Richard Iggo, Nathalie Quenel-Tueux, Marc Debled, Justine Rudewicz, Gaetan MacGrogan, Marina Pulido, Louis Mauriac, Florence Dalenc, Thomas Bachelot, Barbara Lortal, Christelle Breton-Callu, Nicolas Madranges, Christine Tunon de Lara, Marion Fournier, Hervé Bonnefoi, Hayssam Soueidan, Macha Nikolski, Audrey Gros, Catherine Daly, Henry Wood, Pamela Rabbitts, Richard Iggo

Abstract

Background: The aim of this study was to assess the efficacy of neoadjuvant anastrozole and fulvestrant treatment of large operable or locally advanced hormone-receptor-positive breast cancer not eligible for initial breast-conserving surgery, and to identify genomic changes occurring after treatment.

Methods: One hundred and twenty post-menopausal patients were randomised to receive 1 mg anastrozole (61 patients) or 500 mg fulvestrant (59 patients) for 6 months. Genomic DNA copy number profiles were generated for a subgroup of 20 patients before and after treatment.

Results: A total of 108 patients were evaluable for efficacy and 118 for toxicity. The objective response rate determined by clinical palpation was 58.9% (95% CI=45.0-71.9) in the anastrozole arm and 53.8% (95% CI=39.5-67.8) in the fulvestrant arm. The breast-conserving surgery rate was 58.9% (95% CI=45.0-71.9) in the anastrozole arm and 50.0% (95% CI=35.8-64.2) in the fulvestrant arm. Pathological responses >50% occurred in 24 patients (42.9%) in the anastrozole arm and 13 (25.0%) in the fulvestrant arm. The Ki-67 score fell after treatment but there was no significant difference between the reduction in the two arms (anastrozole 16.7% (95% CI=13.3-21.0) before, 3.2% (95% CI=1.9-5.5) after, n=43; fulvestrant 17.1% (95%CI=13.1-22.5) before, 3.2% (95% CI=1.8-5.7) after, n=38) or between the reduction in Ki-67 in clinical responders and non-responders. Genomic analysis appeared to show a reduction of clonal diversity following treatment with selection of some clones with simpler copy number profiles.

Conclusions: Both anastrozole and fulvestrant were effective and well-tolerated, enabling breast-conserving surgery in over 50% of patients. Clonal changes consistent with clonal selection by the treatment were seen in a subgroup of patients.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Flow chart of patient enrolment and analysis populations. Two patients withdrew their consent and did not start the allocated treatment; a total of 118 patients (60 anastrozole and 58 fulvestrant) were thus assessable for safety. Six patients did not meet the eligibility criteria: four had grade 3 tumours and were younger than 65 years, one had an N2 nodal status, and one had bone metastases. A further four patients were not assessable for the primary end point: one patient refused both evaluation at 6 months and surgery; two patients stopped treatment before the 6 months due to toxicity (one elderly patient had asthenia and vertigo after 4 months of fulvestrant treatment with stable disease and was offered treatment with anastrozole, and one patient had musculoskeletal pain after 2 months of anastrozole); and the fourth patient was lost to follow-up. A total of 108 patients were thus assessable and eligible for the primary efficacy end point.
Figure 2
Figure 2
Plots showing ER, PR, Ki-67 and response. (A and B) Oestrogen receptor; (C and D) progesterone receptor; (E and F) Ki-67; (A, C and E) anastrozole arm; (B, D and F) fulvestrant arm. When points fall below the diagonal line (y=x) in each plot, the measured variable declined after treatment. At least 1000 tumour cells per tumour were counted to estimate the percentage with Ki-67-positive nuclei. The axes are plotted on a log scale for Ki-67 because Ki-67 has a log-normal distribution. The area of the plotting symbols is proportional to the number of cases at a given point (e.g., many samples in the anastrozole arm had 100% ER-positive nuclei before and after treatment, so the plotting symbols are larger for these values).
Figure 3
Figure 3
Heatmap showing hierarchical clustering of the 20 samples (H01-H20) before (Bx) and after (Ch) treatment. All tumours except H06Ch2 have abnormalities of chr1 and/or chr16. Colours: yellow, increase in copy number; blue: decrease in copy number. One node has been flipped to highlight the differences between H13 before and after treatment.
Figure 4
Figure 4
Genomic analysis before and after treatment of tumour H09. (A) Plots showing the copy number ratio before vs after treatment of the indicated genes within amplified regions (H09, blue dot; other tumours, black dots). The copy number of ESR1, ATG5 and MSH2 increases after treatment, whereas that of PPM1D, PAK1 and NCOA3 is unchanged. The grey horizontal lines show the 0.999th quantiles of the ratios. (B) Genomic profiles showing the genes in A marked with arrows. (C and D) FISH for ESR1 before treatment (C) and after treatment (D). The red probe detects the centromere of chromosome 6, the green probe detects the ESR1 gene.
Figure 5
Figure 5
Genomic copy number profiles before and after treatment. (A) Tumour H13. (B) Tumour H08. (C) Tumour H10. (D) Tumour H19. Gains and losses of whole chromosomes or chromosome arms are seen after treatment. In many cases, these changes produce a less abnormal profile (see text for details).

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