Paclitaxel, Cyclophosphamide & Doxorubicin, Autologous Dendritic Cells & Surgery in Stage II/III Breast Cancer (Women)
Condition: Breast Cancer
MeSH terms: Breast Neoplasms
Study type: Interventional
Phase: Phase 2

Summary: 
      RATIONALE: Drugs used in chemotherapy, such as paclitaxel, cyclophosphamide, and doxorubicin,
      work in different ways to stop the growth of tumor cells, either by killing the cells or by
      stopping them from dividing. Injecting the patient's dendritic cells directly into the tumor
      may stimulate the immune system and stop tumor cells from growing. Radiation therapy uses
      high-energy x-rays to kill tumor cells. Estrogen can cause the growth of breast cancer cells.
      Hormone therapy using tamoxifen may fight breast cancer by blocking the use of estrogen by
      the tumor cells. Giving combination chemotherapy together with autologous dendritic cells
      before surgery may make the tumor smaller and reduce the amount of normal tissue that needs
      to be removed. Giving radiation therapy and hormone therapy after surgery may kill any tumor
      cells that remain after surgery.

      PURPOSE: This phase II trial is studying the side effects and how well giving paclitaxel
      together with cyclophosphamide and doxorubicin followed by autologous dendritic cells and
      surgery with or without radiation therapy and/or hormone therapy works in treating women with
      stage II or stage III breast cancer.
    

Detailed description: 
      OBJECTIVES:

        -  Assess the safety of intratumoral (IT) autologous dendritic cell (DC) injection in women
           with stage II or III breast cancer receiving neoadjuvant paclitaxel, cyclophosphamide,
           and doxorubicin hydrochloride followed by surgery with or without adjuvant radiotherapy
           and/or hormone therapy.

        -  Determine the clinical and pathologic response in patients treated with this regimen.

        -  Determine the immune response, in terms of tumor cell apoptosis and the presence and
           characterization of tumor infiltrating white blood cells in resected breast cancer, in
           patients treated with this regimen.

        -  Determine if IT DC injections administered during neoadjuvant chemotherapy-induced tumor
           cell apoptosis can induce T-cell responses to tumor antigens in these patients.

      OUTLINE: This is an open-label study.

        -  Leukapheresis: Patients undergo leukapheresis at baseline to collect peripheral blood
           mononuclear cells for dendritic cell (DC) culture.

        -  Neoadjuvant, dose-dense chemotherapy: Patients receive paclitaxel IV over at least 3
           hours on day 1 and filgrastim (G-CSF) subcutaneously (SC) on days 4-14 or pegfilgrastim
           SC on day 2. Treatment repeats every 2 weeks for up to 4 courses in the absence of
           disease progression or unacceptable toxicity.

      Beginning 2 weeks after completion of paclitaxel chemotherapy, patients receive
      cyclophosphamide IV and doxorubicin hydrochloride IV on day 1 and G-CSF SC on days 4-14 or
      pegfilgrastim SC on day 2. Treatment repeats every 2 weeks for up to 4 courses in the absence
      of disease progression or unacceptable toxicity.

        -  Intratumoral injection of autologous DCs: Intratumoral autologous DCs are injected into
           the primary breast mass or palpable axillary node on day 7 of the 1st, 2nd, and 3rd
           courses of paclitaxel chemotherapy. If no tumor can be localized by ultrasound after a
           course of chemotherapy, the DCs are then injected into the site of the tumor bed
           previously localized by clip or marker. In the event that the previously injected
           primary tumor cannot be localized by ultrasound, a palpable lymph node, if still
           present, should be injected rather than the tissue next to the primary tumor clip or
           marker.

        -  Definitive breast surgery: Within 2-4 weeks after completion of neoadjuvant
           chemotherapy, patients undergo modified radical mastectomy or lumpectomy with or without
           standard axillary node dissection.* NOTE: *Standard axillary node dissection is only
           required if no node assessment was done prior to chemotherapy or if the pre-chemotherapy
           sentinel node was positive.

        -  Radiotherapy: Patients undergoing lumpectomy or those with residual disease requiring
           chest wall radiotherapy after mastectomy (e.g., T3 or T4 breast lesions or 4 or more
           axillary lymph nodes) undergo radiotherapy 2-4 weeks after surgery.

        -  Hormone therapy: Patients with estrogen and/or progesterone receptor-positive tumors
           receive adjuvant hormone therapy for ≥ 5 years. Premenopausal patients receive tamoxifen
           citrate and post- or perimenopausal patients receive either tamoxifen citrate or an
           aromatase inhibitor (AI), or both of these drugs in sequence, as determined by the
           treating oncologist.

      Peripheral blood samples are obtained during each DC injection, at staging/biopsy, and then
      periodically for up to 2 years. Blood samples are analyzed by ELISPOT and ELISA assays for
      evaluation of immune response.

      Tumor tissue is obtained by core biopsy of the breast primary and/or palpable axillary lymph
      node at baseline and again after completion of paclitaxel chemotherapy. Tumor tissue is
      analyzed by IHC and RT-PCR for COX-2 and VEGF-A and -C expression levels, as well as T-cell
      and DC infiltration of the tumor. T-cell and DC infiltration is evaluated for correlation
      with clinical outcomes at diagnosis, at the midpoint biopsy following paclitaxel
      chemotherapy, and at definitive surgery.

      After completion of study therapy, patients are followed periodically for up to 2 years.
    

Intervention name(s): therapeutic autologous dendritic cells; aromatase inhibition therapy; cyclophosphamide; doxorubicin hydrochloride; paclitaxel; tamoxifen citrate; gene expression analysis; protein expression analysis; reverse transcriptase-polymerase chain reaction; immunoenzyme technique; immunohistochemistry staining method; laboratory biomarker analysis; adjuvant therapy; biopsy; conventional surgery; neoadjuvant therapy; radiation therapy
Intervention type(s): Biological; Drug; Drug; Drug; Drug; Drug; Genetic; Genetic; Genetic; Other; Other; Other; Procedure; Procedure; Procedure; Procedure; Radiation
Intervention description(s): injected into the primary breast mass or palpable axillary node, one week after the first, second and third T treatments. If, after a cycle(s) of chemotherapy, no tumor can be localized by ultrasound, the DCs will be injected where the tumor bed was localized by the clip or marker.; Adjuvant hormone therapy for patients having tumors with estrogen and/or progesterone receptors. Premenopausal patients will be treated with tamoxifen. Post or perimenopausal women may receive tamoxifen or an aromatase inhibitor (AI) or those drugs in sequence as determined by the treating oncologist. Hormone therapy will be given for at least 5 years.; 600 mg/m2 IV day 1 every 2 weeks for 4 cycles; 60 mg/m2 IV day 1 every 2 weeks for 4 cycles; 175 mg/m2 intravenously (IV) over at least 3 hours day 1 every 2 weeks for 4 cycles.; Adjuvant hormone therapy for patients having tumors with estrogen and/or progesterone receptors. Premenopausal patients will be treated with tamoxifen. Post or perimenopausal women may receive tamoxifen or an aromatase inhibitor (AI) or those drugs in sequence as determined by the treating oncologist. Hormone therapy will be given for at least 5 years.; IHC for CEA and Survivin with appropriate controls will be done on the tumor biopsy material (preferably from the initial diagnostic biopsy).; Tumor biopsymaterial (preferably from the initial diagnostic biopsy) will be stained by IHC with appropriate controls for COX-2, VEGF A, T cell and Dendritic Cell infiltration.; delta Ct (quantitative real time- reverse transcription-polymerase chain reaction (qRT-PCR)) of COX-2 and VEGF will be divided into the upper or lower median and Fisher Exact test used to assess the difference in response.; Estrogen and progesterone receptor, Her2/neu testing: Tumor biopsy material (preferably the initial diagnostic biopsy if tissue is available) will be examined by Immunohistochemistry (IHC) with appropriate controls for estrogen, progesterone receptors and Her2/neu. If the IHC is 2+ or in the indeterminate range, further testing of over-expression of Her2/neu by fluorescent in situ hybridization (FISH) will be done . If this has already been done and reported by the referring hospital, it will not be repeated. These tests are standard of care.
CEA and Survivin testing: IHC for CEA and Survivin with appropriate controls will be done on the tumor biopsy material (preferably from the initial diagnostic biopsy).
COX-2 and VEGF A , T cell and Dendritic Cells: Tumor biopsymaterial (preferably from the initial diagnostic biopsy) will be stained by IHC with appropriate controls for COX-2, VEGF A, T cell and Dendritic Cell infiltration.; Estrogen and progesterone receptor, Her2/neu testing: Tumor biopsy material (preferably the initial diagnostic biopsy if tissue is available) will be examined by Immunohistochemistry (IHC) with appropriate controls for estrogen, progesterone receptors and Her2/neu. If the IHC is 2+ or in the indeterminate range, further testing of over-expression of Her2/neu by fluorescent in situ hybridization (FISH) will be done . If this has already been done and reported by the referring hospital, it will not be repeated. These tests are standard of care.
CEA and Survivin testing: IHC for CEA and Survivin with appropriate controls will be done on the tumor biopsy material (preferably from the initial diagnostic biopsy).
COX-2 and VEGF A , T cell and Dendritic Cells: Tumor biopsymaterial (preferably from the initial diagnostic biopsy) will be stained by IHC with appropriate controls for COX-2, VEGF A, T cell and Dendritic Cell infiltration.; Estrogen and progesterone receptor, Her2/neu testing: Tumor biopsy material (preferably the initial diagnostic biopsy if tissue is available) will be examined by Immunohistochemistry (IHC) with appropriate controls for estrogen, progesterone receptors and Her2/neu. If the IHC is 2+ or in the indeterminate range, further testing of over-expression of Her2/neu by fluorescent in situ hybridization (FISH) will be done . If this has already been done and reported by the referring hospital, it will not be repeated. These tests are standard of care.
CEA and Survivin testing: IHC for CEA and Survivin with appropriate controls will be done on the tumor biopsy material (preferably from the initial diagnostic biopsy).
COX-2 and VEGF A , T cell and Dendritic Cells: Tumor biopsymaterial (preferably from the initial diagnostic biopsy) will be stained by IHC with appropriate controls for COX-2, VEGF A, T cell and Dendritic Cell infiltration.; Hormone manipulation Adjuvant hormone therapy for patients having tumors with estrogen and/or progesterone receptors. Premenopausal patients will be treated with tamoxifen. Post or perimenopausal women may receive tamoxifen or an aromatase inhibitor (AI) or those drugs in sequence as determined by the treating oncologist. Hormone therapy will be given for at least 5 years.; Two tumor biopsies will be performed. The first tumor biopsy will be performed before apheresis for diagnostic purposes, and again after completion of the first four chemotherapy treatments. Patients will undergo local anesthesia with lidocaine and 1% epinephrine followed by 1-2 core biopsies of the breast primary and/or palpable axillary node with a 14 gauge, 16 cm. Bard needle or other similar needle. The procedure may be done under ultrasound guidance. If a metal clip or marker has not been previously placed in the tumor, it will be placed before treatment.; Definitive breast surgery Surgery will occur two to four weeks after the last course of chemotherapy. Modified radical mastectomy or lumpectomy and standard axillary dissection could be performed and the specific procedure will be decided by the patient and physician team. If a sentinel node dissection was done prior to chemotherapy and was negative, no further node dissection is necessary. A standard node dissection will be necessary if no node assessment was done prior to chemotherapy or if the pre- chemotherapy sentinel node was positive.; Chemotherapy: Paclitaxel (T) 175 mg/m2 intravenously (IV) over at least 3 hours day 1. Repeat every 2 weeks for 4 cycles. IT DCs will be injected into the primary breast mass or palpable axillary node, one week after the first, second and third T treatments.; Radiation therapy Radiation is started two to four weeks after surgery for all patients receiving lumpectomy and those patients after mastectomy that the physician feels chest wall radiation is warranted (example: T3 or T4 breast lesion, four or more axillary nodes etc.). The exact doses and methods of administration will be determined by the treating radiation therapist, but should be standard breast radiotherapy and not partial breast or investigational methods.
Other intervention name(s): endocrine therapy; Cytoxan; Lipodox, Lipodox 50, and Doxil; Abraxane; Nolvadex
Intervention MeSH terms: Tamoxifen; Paclitaxel; Cyclophosphamide; Doxorubicin; Liposomal doxorubicin; Aromatase Inhibitors
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: stage II breast cancer; stage IIIA breast cancer; stage IIIB breast cancer; stage IIIC breast cancer