REVIEW ONCOLOGY

Should tumour infiltrating lymphocytes and PIK3Ca mutation be added as markers to the histology report for breast cancer?

SUMMARY

Tumour infiltrating lymphocytes are a sign of immune mediated reaction of the host against the tumour. They are considered as a positive prognostic marker and may also have a predictive role for the use of certain therapies. The challenge remains to convert tumours with low tumour infiltrating lymphocytes into tumours with high tumour infiltrating lymphocytes in order to enhance the immune mediated effect of therapies.

PIK3Ca mutation is one of the most frequent mutations encountered in breast cancer, particularly in hormone receptor positive cancer in which it can confer resistance to hormonal therapy. Therefore, a lot of effort has been made to target the PI3K-pathway with drugs, and to find a way to predict their efficacy: some results have been achieved; in particular with the detection of PIK3Ca in circulating DNA, but many questions still remain. This article provides an overview concerning these two biomarkers, and attempts to determine whether they could be used in clinical practice today.

(BELG J MED ONCOL 2017;11(1):7–11)

Gastric cancer: the role of VEGFR2, MET and HER2

Summary

Gastric cancer is one of the leading causes of cancer deaths worldwide. A new molecular classification based on comprehensive genomic analysis is currently replacing the old, clinically pointless classification. This classification based on targetable genomic abnormalities and pathway amplifications may open avenues for clinical research based on targeted medications and strategies. We review three important potential targets in advanced gastric cancer.

(BELG J MED ONCOL 2016;10(7):243–248)

Interest of physical activity in lung cancer care: a systematic review

Summary

Cancers can benefit from physical activity. Most evidences concern breast, prostate and colorectal cancers. Literature about lung cancer and exercise is scarce. However lung cancer is frequent all around the world. The aim of this review was to summarise the knowledge on effects of exercise in lung cancer patients. The benefit of physical activity as a preventive strategy was also analysed.
We systematically searched for studies published between 2008 and 2013. Used key words were lung cancer, physical activity, quality of life, fatigue, functional performance, exercise, rehabilitation, treatment, prevention, complication. The following databases were reviewed: PubMed, ScienceDirect, Chest, Cochrane, SportDiscus and WHO. Eligibility criteria were availability of full texts in English or in French. Studies were classified in four categories: exercises as prevention, in preoperative period, during treatment and after treatment.
Positive effects of exercise were globally demonstrated on physical and psychological outcomes in the four categories. Benefits of exercise were particularly observed for supervised program. Home exercise program benefits were less convincing.
Even if physical activity and exercise programs can be beneficial in prevention, during and after the treatment of lung cancer, the heterogeneity of the literature is too large to reach a conclusion about their place in the treatment.

(BELG J MED ONCOL 2016;10(6):199–206)

State of the art: gene expression profiles in early breast cancer

Summary

Gene expression profiles provide strong prognostic information and can predict breast cancer outcome mainly in women with lymph node-negative, oestrogen receptor-positive, human epidermal growth factor receptor 2-negative breast cancer. They are primarily designed to enable a more precise assessment on whether or not a patient needs adjuvant chemotherapy. However, the optimal use in clinical practice is still not established. The first set of data published from the TAILORx study and the results from the MINDACT study provide strong evidence for the clinical utility of gene expression profiles. Full disclosure of the results of prospective studies such as MINDACT and TAILORx on this topic is awaited in order to define their exact place in clinical decision-making. However, in several countries, these tests are already used in daily clinical practice, and are reimbursed. In addition, the use of gene expression profiles as a potential ancillary tool for treatment decisions is supported in several international treatment guidelines. Multiple studies have shown that there is a change in treatment decision based on gene expression profiles. In addition, different assays may provide different risk stratification at short-, middle- and long-term, so thoughtful use of these tests is recommended. Patients should be well informed about the benefits, risks, costs and uncertainties associated with these tests. Clinicians should also be educated on these matters. Furthermore, as gene expression profiles are expensive and not reimbursed in many countries, these tests are not accessible to all breast cancer patients. Patients’ preferences are important when making risk assessments and treatment decisions in those cases where there is doubt on the benefit of giving adjuvant chemotherapy. Taken together, gene expression profiles provide information that may be complementary to that provided by standard clinicopathological assessment in guiding decision of therapy in the adjuvant setting. These assays represent a step forward towards personalised medicine. We strongly propose to allow reimbursement of gene expression profiles in Belgium, but pragmatic and clear criteria for reimbursement should be developed with all stakeholders to avoid overconsumption.

(BELG J MED ONCOL 2016;10(4):114–122)

Cryotherapy and radiofrequency ablation for renal cell carcinoma

Summary

Thermal ablation is being increasingly used for the treatment of clinical stage T1a renal cell carcinoma. However, it is not uncommon to hear mixed messages regarding this issue. Hence, it is necessary for every urologist to understand the basics of thermal ablation and its clinical outcome based on the latest literature to help guide their patients through treatment options. Patient selection criteria are also analysed. Among thermal ablation techniques, cryotherapy and radiofrequency are the most commonly performed ablative procedures. The superiority of one technique over the other is difficult to demonstrate in the absence of a randomised controlled trial. Local recurrence seems more likely after radiofrequency ablation than after cryotherapy, with the latter achieving better local control. When compared to partial nephrectomy, higher local recurrence rates are described with the thermal ablation techniques. However, the small difference at five year follow-up and the better tolerability profile of thermal ablation procedures in elderly and/or comorbid patients explain the rationale for their use in selected cases. Follow-up is mandatory in these patients to diagnose recurrence or persistence of the disease, to monitor renal function and to detect complications. Of note, redo-techniques and surgical approach, though challenging, remain possible salvage procedures after primary failure.

(BELG J MED ONCOL 2016;10(3):85–91)

Highlights in oncology 2015

Summary

This article is based on the 2016 clinical cancer advances article, published by the American Society of Clinical Oncology, and reviews the most important advances made in the different fields of oncology that are most likely to impact daily clinical practice.¹

(BELG J MED ONCOL 2016;10(2):49–57)

Early triple negative breast cancer in clinical practice

Summary

Up to 20% of breast cancers lack receptors for estradiol, progesterone and human epidermal growth factor receptor 2, triple negative breast cancer. Negativity for these receptors is not completely nor consistently defined. ImmunoHistoChemical/In Situ Hybridisation determined triple negative breast cancer is strong but incomplete compared to the molecular intrinsic basal like subtypes one and two, but also includes non-basal like subtypes. Most triple negative breast cancers are of the histological IDC-NOS type. Triple negative breast cancer in general has unfavourable clinical and prognostic characteristics and is most frequently diagnosed in young women and women with (germline) mutations in BRCA1. Therefore, triple negativity may be an indication for genetic testing of germline BRCA mutations. Lymphocytic infiltration of triple negative breast cancer correlates with a less detrimental prognosis. Triple negative breast cancers often lack mammographic micro calcifications.

Regardless of type of primary surgical treatment, patients with triple negative breast cancer are more at risk for local/regional recurrence than other types. But there is no reason for local/regional treatment or indications for (neo) adjuvant systemic therapy beyond accepted guidelines for breast cancer in general. The mainstay of (neo) adjuvant medical treatment of early triple negative breast cancer is combination (sequential) chemotherapy with anthracyclines and taxanes. Alternatives are pegylated liposomal doxorubicin or classical cyclophosphamide, methotrexate 5-fluorouracil. In triple negative breast cancer with BRCAness, platinums may replace taxanes in neoadjuvant treatment to optimise the pathologic complete response rate. Several targeted therapies proved to be effective in metastatic triple negative breast cancer, but to date there are no such validated treatments for early disease. Besides targeted therapies, immune modulatory strategies for well characterised immunogenic triple negative tumours (i.e. with different grades of lymphocytic infiltration) are promising.

(BELG J MED ONCOL 2016;10(1):7–14)