Non-pegylated liposomal doxorubicin plus cyclophosphamide as first-line therapy in elderly women with HER2 negative metastatic breast cancer.

Background: The use of anthracyclines in metastatic breast cancer (MBC) is limited by cumulative dose-dependent cardiotoxicity mostly in elderly women with comorbidities. The aim of this observational retrospective study was to evaluate the efficacy of non-pegylated liposomal doxorubicin (Myocet®) and cyclophosphamide in elderly women as HER2 negative first-line MBC treatment. Methods: 84 elderly women >70 years of age (median age 78 years) with MBC HER2 negative were enrolled. Performance Status in 58 patients was ECOG-0 and in 26 patients was ECOG-1. Results: The drug was well tolerated, with overall response rates were >40%, median overall survival was 16.2 months (95%CI:14.6-18.8) and median progression free survival was 5.8 months (95%CI:4.4-8.6). Hematologic toxicity with neutropenia was the most frequent adverse event, but the treatment was well tolerated maintained a manageable cardiotoxicity. Conclusion: Non-pegylated liposomal doxorubicin may represent a valid therapeutic option in first-line for elderly patients with HER/2 negative MBC improving survival, anti-tumor response rate and de-creases cardiotoxicity.

[Molecular approach in the treatment of dermatofibrosarcoma protuberans]. / Approccio molecolare nella terapia del dermatofi brosarcomaprotuberans.

Dermatofibrosarcoma protuberans (DFSP) is a cutaneous low-grade malignancy with a high recurrence rate that rarely generates distant metastases. In most cases this tumor is associated with a chromosomal translocation involving the COL1A1 gene on chromosome 17 and the platelet-derived-growth-factor B gene on chromosome 22, generating a fusion gene that constitutively activates the PDGF receptor (PDG-FR). In the early stages of disease traditional surgery (wide excision) or Mohs micrographic surgery represent the standard of care. When surgical margins are positive, postoperative radiotherapy is a valuable option. Recently it has been shown that inhibiting PDGFR with imatinib can induce a high response rates in case of unresectable or metastatic disease. This targeted agent now represents the therapy of choice of advanced DFSP and it is the fi rst great therapeutic success in this disease after unsuccessful years using cytotoxic drugs. It is likely that a better knowledge of molecular biology of DFSP could, as it was the case for GISTs, may improve treatment results leading to the development of new targeted agents.

[Development of docetaxel in the adjuvant chemotherapy of breast cancer]. / Sviluppo del docetaxel nella chemioterapia adiuvante del cancro della mammella.

The development of taxanes in cancer chemotherapy required several decades of research mainly because of the difficulty related to supply and formulation of paclitaxel. Lesser difficulty was encountered in the development of docetaxel, which initially took place in breast cancer. In this disease, docetaxel showed a significant activity, probably superior to that of paclitaxel. In the first-generation studies in patients with early breast cancer, comparing anthracycline-based regimens with regimens containing anthracyclines and taxanes, docetaxel significantly improved survival independently from schedule, either sequential or concurrent. The aim of current second-generation studies, comparing taxanes in all study arms, is to answer several questions, including the best administration schedule and the best taxane to be used. Currently, the use of docetaxel in the adjuvant chemotherapy of breast cancer represents one of the most important achievements in the treatment of this disease. However, since further improvement in therapeutic results are needed, it is likely that in the future docetaxel will be used in combination with molecular targeted agents.

[Target selectivity of anticancer drugs]. / Specifi cità d'azione dei farmaci antitumorali.

Since the first use of chemotherapy, many efforts were devoted to develop drugs with a specific anticancer activity. Nevertheless, although several approaches to this end were used leading to significant results in cancer treatment, chemotherapy has mainly a palliative effect. The remarkable scientific advances in the knowledge of molecular changes in neoplastic diseases brought to development of new drugs with a specific molecular target. In some cases, this approach against a single molecular target, has been extremely successful, like imatinib in GIST. However, since in most cases tumor growth involves multiple genetic changes, it seems more appropriate to develop multitargeted agents. A successful way to improve target selectivity of anticancer drugs and to better choose patients to treat could be the use phase 0 clinical trials. In the future, the hope is to discover all genetic changes in each cancer patient and to restore the normal function of the cell with the aid of more advanced technologies.

Docetaxel in the adjuvant therapy of HER-2 positive breast cancer patients.

Considering the clinical benefit of trastuzumab in advanced breast cancer, fi ve prospective adjuvant randomized trials have recently been completed and early results have been published. Two of them, (NSABP-B31 and NCCTG N9831), employed anthracycline-containing regimens with sequential paclitaxel, with or without trastuzumab. The third study, HERA trial, randomized patients after adjuvant chemotherapy into an observational arm, one or two years of trastuzumab. Results of these studies, after a median follow up of 2-3 years confirm a DFS and OS benefit for the experimental arms. The worst rate of cardiotoxicity, in terms of incidence of CHF, with the use of trastuzumab and anthracycline based regimens was 4.1% in the trastuzumab arm of the NSABP-B31 trial. Among the fi ve trastuzumab trials, two, BCIRG 006 and FinHer, employed docetaxel-based regimens. The innovative BCIRG 006 trial compared ACdocetaxel (T) with two trastuzumab-containing regimens, ACTH, and a non-anthracycline-containing regimens, TCH, with a clear advantage in DFS for both trastuzumab arms. Data from the second interim analysis indicate that, in the subgroup of patients without co-amplification of topoisomerase 2 (TOPO-2), the arm without trastuzumab (ACT) showed a DFS significantly poorer that in the other arms; moreover, if we consider the lower toxicity of TCH regimen in comparison with anthracycline-containing arms, the innovative statements offered by BCIRG 006 trial appear evident, and these findings opened an important question about the consolidated employment of anthracyclines in adjuvant setting.The FinHer trial was a small trial testing a short course of trastuzumab (9 weeks) concomitantly with a chemotherapy including docetaxel, and there was a significant advantage in DFS for the trastuzumab based arms, without relevant toxicity and without any cardiotoxicity. Although data from all trastuzumab adjuvant trials, and without particulary from BCIRG-006 and FinHer trials, appear very intriguing, further follow-up is required.

Optimal sequence of anthracyclines and taxanes as adjuvant breast cancer treatment.

Results from randomized trials evaluating taxane versus non-taxane containing regimens in adjuvant breast cancer treatment indicate an advantage in DFS and OS for the taxane-arms, but the best schedule of administration, in combination with anthracyclines or in sequence, is still a debated issue, even if the sequential strategy appears to be less toxic. Up to now, the majority of clinical trials employed the "standard" sequence, with anthracycline-based combinations fi rst, followed by taxanes. Few small phase II trials evaluated the reverse sequence, with taxanes administered fi rst, most of them in metastatic or neoadjuvant setting, suggesting efficacy and lower toxicity. An important issue to be considered is the hypothesized differences in the ability of the drugs to induce cross-resistance to each other, as suggested by data of a preclinical study, and from clinical study with a cross-over design; results of these trials suggest that the best strategy would be to administer a taxane prior to an anthracycline, also according to the Norton and Simon hypothesis. Moreover, trials evaluating the best sequence of anthracyclines and taxanes in adjuvant breast cancer setting are of small sample size, and an adequately powered randomized phase III trial is needed before definitive conclusions are reached.

[Optimal role of docetaxel in adjuvant chemotherapy for early stage HER2-negative breast cancer]. / Uso ottimale del docetaxel nella chemioterapia adiuvante delle pazienti con carcinoma mammario HER2-negativo.

The fundamental imperative of adjuvant treatment of early breast cancer is to improve long-term survival and minimize toxicity. The inclusion of docetaxel in adjuvant chemotherapy regimens has improved patient survival in comparison to anthracycline-containing regimens, even if the incidence of acute side effects has increased in some studies. However, late or persistent toxic effects are becoming more important due to an increasing proportion of patients remaining disease free after treatment for early breast cancer. Several studies have recently reported that docetaxel-containing regimens without anthracyclines are equally active, and have no apparent cardiotoxicity. At present, docetaxel-based combinations represent an appropriate choice in the adjuvant treatment of HER2-negative breast cancer, and several studies are ongoing aiming at a better evaluation of the efficacy of this agent in order to optimize its role.