Trastuzumab in combination with metronomic = cyclophosphamide and methotrexate in patients with HER-2 positive = metastatic breast cancer

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Journal = List >=20 BMC=20 Cancer > v.6= ;=20 2006

Abstract

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PubMed articles by:

Orlando, L.

Cardillo, A.

Ghisini, R.

Colleoni, M.

BMC Cancer. 2006; 6: 225.

Published online 2006 September = 15. doi: = 10.1186/1471-2407-6-225.

Trastuzumab in combination with metronomic=20 cyclophosphamide and methotrexate in patients with HER-2 positive=20 metastatic breast cancer

Laura Orlando,¹=20 Anna Cardillo,¹ Raffaella Ghisini,¹ Andrea=20 Rocca,¹ Alessandra Balduzzi,¹ Rosalba=20 Torrisi,¹ Giulia Peruzzotti,¹ Aron=20 Goldhirsch,² Elisabetta Pietri,¹ and Marco=20 Colleoni¹

¹Unit of Research in Medical = Senology,=20 Department of Medicine, European Institute of Oncology, Via = Ripamonti 435,=20 20141 Milan, Italy

²Division of Medical Oncology, = Department of=20 Medicine, European Institute of Oncology, Via Ripamonti 435, 20141 = Milan,=20 Italy

Corresponding=20 author.

Laura = Orlando: laura.orlando@ieo.it; = Anna Cardillo: anna.cardillo@ieo.it; = Raffaella Ghisini: raffaella.ghisini@ieo.it;=20 Andrea Rocca: andrea.rocca@ieo.it; = Alessandra Balduzzi: alessandra.balduzzi@ieo.it= ;=20 Rosalba Torrisi: rosalba.torrisi@ieo.it; = Giulia Peruzzotti: giulia.peruzzotti@ieo.it;=20 Aron Goldhirsch: aron.goldhirsch@ibcsg.org; = Elisabetta Pietri: elisabetta.pietri@ieo.it;=20 Marco Colleoni: marco.colleoni@ieo.it

Received June 12, 2006; Accepted September 15, 2006.

This is an Open Access article distributed under the terms of = the=20 Creative Commons Attribution License (http://www.pubmedcentral.nih.gov/redirect3.cgi?&&= ;reftype=3Dextlink&artid=3D1579231&iid=3D125940&jid=3D16&= FROM=3DArticle|Front%20Matter&TO=3DExternal|Link|URI&article-id=3D= 1579231&journal-id=3D16&&http://creativecommons.org/licenses/= by/2.0),=20 which permits unrestricted use, distribution, and reproduction in = any=20 medium, provided the original work is properly=20 cited.

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"=20 = src=3D"http://www.pubmedcentral.nih.gov/corehtml/pmc/pmcgifs/square.gif" = border=3D0>Abstract

Background

Methods

Results

Discussion

Conclusion

Abbreviations

Competing=20 interests

Authors'=20 contributions

Pre-publication history

References

Abstract

Background

HER2/neu=20 overexpression is linked to promotion of angiogenesis in = breast=20 cancer. We therefore tested the activity of the combination of = Trastuzumab=20 with metronomic, low dose chemotherapy with cyclophosphamide (CTX) = and=20 methotrexate (MTX) in metastatic breast cancer (MBC).

Methods

Between April = 2002 and=20 June 2005, twenty-two patients with metastatic breast cancer with = the=20 presence of overexpression or amplification of HER2-/neu, = all=20 pre-treated with trastuzumab plus other cytotoxics, were treated = with=20 trastuzumab (6 mg/kg every three weeks) in combination with = metronomic=20 chemotherapy (MTX 2.5 mg, bid on Day 1 and Day 4 every week) and = CTX (50=20 mg daily) (CM).

Results

The 22 = enrolled patients=20 are evaluable: most had an ECOG performance status of 0 (17 pts), = and all=20 were pre-treated with chemotherapy for metastatic disease; 14 had=20 progressive disease at study entry, and 11 had progressive disease = during=20 the last trastuzumab therapy. Metastatic sites included: lung (5 = pts),=20 liver (14 pts), bone (12 pts), lymph nodes (8 pts), central = nervous system=20 (CNS) (9 pts). We observed 4 partial remission (PR) (18%, 95% CI = 5=E2=80=9340%),=20 10 stable disease (SD) (46%, 95% CI 24=E2=80=9368%), and 8 PD = (36%, CI 17=E2=80=9359%).=20 The clinical benefit (RP plus RC plus SD for =E2=89=A5 24 weeks) = in all pts and in=20 pts with disease resistant to previous trastuzumab therapy were = 46% (95%=20 CI, 24=E2=80=9368%) and 27% (95% CI, 6=E2=80=9361%), respectively. = Median time to=20 progression was 6 months and median duration of treatment was 5 = months=20 (range, 0,7 to 18.4 months and range, 1 to 18 months, = respectively).=20 Overall clinical toxicity was generally mild. Grade =E2=89=A52 = reversible liver=20 toxicity and leukopenia were reported in 5 and 3 pts, = respectively.

Conclusion

The = combination of=20 trastuzumab and metronomic chemotherapy is effective and minimally = toxic=20 in advanced breast cancer patients. The efficacy observed in = patients with=20 disease resistant to trastuzumab supports the need of larger trial = to=20 confirm a role of this combination to delay acquired trastuzumab=20 resistance.

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Abstract

"=20 = src=3D"http://www.pubmedcentral.nih.gov/corehtml/pmc/pmcgifs/square.gif" = border=3D0>Background

Methods

Results

Discussion

Conclusion

Abbreviations

Competing=20 interests

Authors'=20 contributions

Pre-publication history

References

Background

Malignant tumors secrete factors that enable them to trigger = their own=20 angiogenesis. The initiation of angiogenesis requires acquisition = of the=20 angiogenic phenotype through a series of molecular events leading = to=20 increased expression of angiogenic factors and down-regulation of = natural=20 inhibitors [1].

Her2/neu is a 185-kilodalton transmembrane receptor tyrosine = kinase=20 that belongs to the epidermal growth factor receptor family [2,3].=20 Tumor overexpression of HER2/neu is present in about 30% of = patients with=20 breast cancer and is associated with a worse histological grade, = decreased=20 overall survival and altered sensitivity to chemotherapeutic = agents [4,5].=20 Recently, Her2/neu has been implicated in tumor angiogenesis. = Experimental=20 studies suggest that neutralizing antibodies against Her2/neu or = EGFR=20 results in down-regulation of angiogenesis, through VEGF gene = suppression=20 [6].=20 It is reported in the literature that such interaction occurs = via=20 abrogation of the increased synthesis of HIF1a = (hypoxia=20 inducible factor-1a) induced by c-erbB2 activation by = ligands=20 (i.r. heregulin) [7].=20 Moreover, a hypoxic-independent mechanims has been recently = advocated in=20 the angiogenetic involvement of HER2-/neu [8].

Trastuzumab (Herceptin^=C2=AE; Genentech, South San = Francisco,=20 CA), a recombinant humanized anti-erbB2/HER-2 monoclonal antibody = (MoAb)=20 used in erbB2-overexpressing breast carcinoma, has been shown to = have=20 antiangiogenic properties [9].=20 Trastuzumab can induce normalization and regression of the = vasculature in=20 an experimental human breast tumor which overexpresses HER2 in = mice, by=20 modulating the effects of different pro- and anti-angiogenic = factors [9].=20 The combination of trastuzumab with chemotherapeutic agents = (paclitaxel,=20 docetaxel) has been shown to increase the efficacy of trastuzumab = in=20 reducing angiogenesis in erbB2-overexpressing cells more than = either=20 therapy alone both in animal models and clinical studies [10,11].

We previously demonstrated the antitumor activity of oral = low-dose=20 methotrexate and cyclophosphamide delivered as metronomic = chemotherapy in=20 metastatic breast cancer and we have shown the correlation with = vascular=20 endothelial growth factor levels [12,13].=20 Other authors previously showed that long-term, low dose = chemotherapy=20 could elicit an antiangiogenic effect [14].

Based on these considerations, we evaluated the activity and=20 tolerability of the combination trastuzumab plus low-dose oral=20 cyclophosphamide and methotrexate in patients with metastatic = breast=20 cancer with overexpression or amplification of Her2-/neu and = pre-treated=20 with trastuzumab.

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Abstract

Background

"=20 = src=3D"http://www.pubmedcentral.nih.gov/corehtml/pmc/pmcgifs/square.gif" = border=3D0>Methods

Results

Discussion

Conclusion

Abbreviations

Competing=20 interests

Authors'=20 contributions

Pre-publication history

References

Methods

Patient selection

Patients = included=20 were required to have histologically confirmed metastatic breast = carcinoma=20 that either had, or had not, progressed after a line of = trastuzumab alone=20 or in combination with chemotherapy for metastatic disease. Other=20 inclusion criteria were: measurable disease, age =E2=89=A4 80 = years, performance=20 status ECOG < 3, adequate bone marrow reserve defined as white = blood=20 cells > 4,000 mm³and platelets > 100,000 = mm³,=20 adequate renal function (serum creatinine < 120 =CE=BCmol/l) = and hepatic=20 function (serum bilirubin < 20 =CE=BCmol/l, AST (SGOT) < 60 = IU/l). It was=20 mandatory that all patients had to have recovered from any prior=20 chemotherapy, radiotherapy, or surgery before the start of = treatment.

Each patient included in this study gave their written informed = consent. This protocol was notified to Ethical Committee.

Evaluation and = treatment

Baseline=20 evaluation included clinical examination, chest X-ray, liver = ultrasound or=20 CT scan, bone nuclear scan (plus segmental bone radiographs when = bone=20 scans were positive), ECG, echocardiography with LVEF evaluation, = and=20 complete biochemical and hematological tests. A complete blood = count was=20 repeated every 14 days and biochemical tests every 28 days. = Cardiac=20 assessment via echocardiography with LVEF evaluation was performed = every 3=20 months.

HER2/neu overexpression was assessed on routinely processed,=20 formalin-fixed, paraffin-embedded tissue by immunohistochemical=20 investigations using an automated immunostainer (TechMate 500; = Dako,=20 Glostrup, Denmark) and a peroxidase-based detection system in kit = form=20 (ChemMate; Dako) according to the manufacturer's instructions. The = primary=20 specific monoclonal antibody used was clone CB11; Biogenex. The = FISH test=20 was performed on routinely processed, formalin-fixed, = paraffin-embedded=20 tissues using PathVision Her-2 DNA Probe Kit (Vysis Inc, Doweners = Grove=20 I11, and Inform HER-2 Gene Detection System, Ventana Medical = Systems, Inc,=20 Tucson, Arizona)

Patients were treated with MTX orally at a dose of 2.5 mg twice = a day=20 on day 1 and 4 every week (10 am, 5 pm) and CTX orally at a dose = of 50 mg=20 a day (9 am) in combination with Trastuzumab (Herceptin^{=C2=AE =}6=20 mg/kg every three weeks, after a loading dose of 8 mg/kg at the = first=20 administration)

Side effects and = response

Toxicity=20 was evaluated according to National Cancer Institute's (NCI) = Common=20 Terminology Criteria for Adverse Events (CTCAE) version 2.0

Treatment was withheld and delayed for 1 week in cases of a = neutrophil=20 count of less than 1,000 mm³and/or platelet count less = than=20 75,000 mm³. A 50% dose reduction in the total amount of = drug=20 administered in each cycle was prescribed after hematological = recovery. In=20 cases of a neutrophil count less than 1,500 mm³but = > 1,000=20 mm³and/or platelet count less than 100,000 mm but = >75,000=20 mm³therapy was administered with a 50% dose reduction = in the=20 total amount of drug administered in each cycle. Re-escalation of = drug=20 doses was attempted if close monitoring was possible.

In the event of grade =E2=89=A5 2 anorexia, nausea, vomiting, = diarrhea,=20 stomatitis, dryness of the mouth, epigastric pain, increase in=20 transaminases, all therapy was postponed until symptoms subsided. = A 50%=20 reduction of CM was performed for the next cycle, with subsequent=20 re-escalation to full dosage if tolerated. Any other = non-hematological=20 Grade 3 toxicity was managed by a 50% reduction of dosage in the = next=20 cycle, which was not commenced until full recovery had occurred. = Cardiac=20 function was monitored with echocardiography every 3 months and = therapy=20 with Herceptin was interrupted for values of Ejection Fraction = (EF) below=20 50 or in cases of reduction of =E2=89=A4 10% from baseline = value.

Assessment of response was conducted according to WHO criteria = and was=20 performed after every 8 weeks of therapy. CR was defined as the=20 disappearance of all known lesions on two separate measurements at = least 4=20 weeks apart. PR was defined as a reduction of each lesion by at = least 50%.=20 SD was defined as a decrease of less than 50% or an increase of = less than=20 25% with no new lesions, and progressive disease as an increase of = more=20 than 25% or appearance of new lesions. Clinical benefit was = defined as the=20 proportion of patients who achieved CRs, PRs, or SDs for at least = 24=20 weeks.

Statistical analysis

The = study was=20 conducted with a two-stage design according to Gehan. In order to = attain a=20 power of 0.9 to detect a response rate of 20%, 11 patients are = required in=20 the first stage and if none demonstrates a response the study must = be=20 closed because of lack of activity. Because two patients = responded, a=20 further eleven patients were required to reach a precision of 0.1 = in the=20 estimate of the true response rate. Confidence intervals for the = response=20 rates were calculated using exact binomial methods.

Estimated curves of time to progression were plotted from the = first day=20 of treatment by the method of Kaplan and Meier; response duration = was=20 measured from the date of achievement of response. The association = between=20 categorical variables was assessed by the Fisher exact test.

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Abstract

Background

Methods

"=20 = src=3D"http://www.pubmedcentral.nih.gov/corehtml/pmc/pmcgifs/square.gif" = border=3D0>Results

Discussion

Conclusion

Abbreviations

Competing=20 interests

Authors'=20 contributions

Pre-publication history

References

Results

Between April 2002 and June 2005, twenty two metastatic breast = cancer=20 patients were treated with the combination of trastuzumab and = metronomic=20 chemotherapy. All patients but one demonstrated overexpression of=20 Her2-/neu (3+) (seven patients determined in the primary (32%) and = fifteen=20 patients in the metastatic sites (68%). The FISH test was = performed in the=20 tumor with overexpression of Her2/neu (2+) and resulted positive = for=20 amplification of the gene. Progressive disease at study entry was=20 registered in 14 patients; among these, 11 patients had = progressive=20 disease during trastuzumab-containing regimens as the last = treatment=20 before study entry. Moreover, one patient had progressive disease = during=20 the last trastuzumab-containing therapy (not the last treatment = before=20 study entry) (Table 1).=20 Previous trastuzumab-containing regimens are showed in Table 1.=20 Median follow-up was 15 months. All patients had measurable = disease.

Oral cyclophosphamide plus methotrexate in combination with = trastuzumab=20 produced 4 PRs providing an objective response rate of 18% (95% CI = 5=E2=80=9340%).=20 An additional 10 patients had stabilization of disease and of = these, 6=20 patients showed long-term disease stabilization (SD after 24 = weeks),=20 providing an overall clinical benefit (CR + PR + SD after 24 = weeks) of 46%=20 (95% CI 24=E2=80=9368%). Previous treatments in patients achieving = clinical=20 benefit are summarized in Table 2.

Patients achieving clinical benefit were all pre-treated with = =E2=89=A5 2 lines=20 of chemotherapy for metastatic disease and with at least one line = of=20 Trastuzumab containing regimen. The clinical benefit in patients = with=20 progressive disease at study entry was 36% (95 % = CI,13=E2=80=9365%) (Table 2).=20 Two patients among those who achieved PR and three patients among = those=20 who achieved prolonged disease stabilization had progressive = disease at=20 study entry. In particular, 3 patients had progressive disease to=20 trastuzumab-containing combinations and 2 to trastuzumab-non = containing=20 regimen. Moreover one patient had progressive disease to the last=20 trastuzumab-containing therapy (not performed as the last therapy = before=20 study entry). The clinical benefit in patients who progressed = during the=20 trastuzumab-containing regimen (trastuzumab-resistant) was 27% (3 = pts out=20 of 11, 95% CI, 6=E2=80=9361%).

Exploratory analysis on features associated with the = achievement of a=20 clinical benefit showed a trend toward a larger percentage of = clinical=20 benefit among patients who received only one previous line of = trastuzumab=20 plus chemotherapy (62%, 8 out of 13) compared with those who = received more=20 than one previous line (22%, 2 out of 9)

Median time to response was 2 months and, among responding = patients,=20 the median duration of response was 8.8 (range: 1=E2=80=9312 + = months.). Median=20 time to progression was 6 months (range 0.7=E2=80=9318.4 +; 95% = CI, 3.6 to inf)=20 and median duration of treatment was 5 months (range, 1 to 18+=20 months).

A total of 149 months of therapy were administered, median per = patient=20 5 months. Only 3 patients (13.6%) had delayed chemotherapy and = only 3=20 (13.6%) reduced dosages of MTX. Reasons for delay and dose = reduction was=20 mainly leukopenia and increase in transaminases. Table 3=20 summarizes the side effects observed. Treatment was well = tolerated. The=20 most frequently encountered toxicity was grade II leukopenia, = which was=20 observed in 14% of the cases. Increase in transaminase values were = registered in 8 cases (36%) (2 cases with grade III).

No cardiotoxicity was reported with the exception of one = patient with=20 decreasing value of ejection fraction (EF) to 51% (less than 10% = from=20 baseline value) after one month of the trastuzumab therapy plus CM = and=20 after more than 1 year of the other trastuzumab-chemotherapy=20 combinations.

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Abstract

Background

Methods

Results

"=20 = src=3D"http://www.pubmedcentral.nih.gov/corehtml/pmc/pmcgifs/square.gif" = border=3D0>Discussion

Conclusion

Abbreviations

Competing=20 interests

Authors'=20 contributions

Pre-publication history

References

Discussion

The combination of trastuzumab with chemotherapeutic agents is = a well=20 established approach for treatment of HER2 positive metastatic = breast=20 cancer. Preclinical models and subsequent clinical data have = demonstrated=20 an additive or synergistic effect of the combination with platinum = salts,=20 paclitaxel, docetaxel, vinorelbine or more than one drugs [15-18].

Unfortunately, the success of these combinations in responding = patients=20 is compromised by the development of acquired resistance [4].=20 The mechanism of resistance to trastuzumab in animal models is the = consequence of heritable genetic alterations and involved = different,=20 independent mechanisms [19].=20 The opportunity, in patients with progressive disease, of = continuing=20 trastuzumab combined with a non cross resistant chemotherapeutic = regimen=20 is a crucial question regarding trastuzumab strategy. Data on = restored=20 efficacy of trastuzumab with further associations after failure = are=20 limited, although some activity was recently reported in patients = with=20 progressive disease during trastuzumab therapy regarding a further = non=20 cross resistant chemotherapeutic regimen in combination with = trastuzumab=20 [20-22].

Recently, Kerbel et al reported increased angiogenic activity, = as=20 demonstrated by the up-regulation of VEGF, in tumors resistant to=20 trastuzumab therapy in murine models [19].=20 Using this model, the authors showed that eventual relapses during = trastuzumab therapy can be significantly delayed by prolonged = combination=20 therapy with metronomic low-dose cyclophosphamide chemotherapy. = Another=20 important issue is the preliminary evidence for the superiority of = combining metronomic chemotherapy (cyclophosphamide) versus = standard=20 maximum tolerated dose (MTD) chemotherapy in terms of efficacy and = toxicity.

The current trial, the only clinical experience reported of = metronomic=20 chemotherapy plus trastuzumab for patients with advanced breast = cancer,=20 indicates a role for this combination to possibly delay acquired=20 resistance to trastuzumab, and to treat patients whose tumor = variants have=20 acquired resistance. In our series all patients had received = trastuzumab=20 before commencing the combination of metronomic chemotherapy and=20 trastuzumab and 14 patients had progressive disease at their = inclusion in=20 the study. The majority of them were progressive during=20 trastuzumab-containing regimen (11 patients) as the last therapy = before=20 study entry. We observed a clinically significant activity in both = patients with progressive disease at study entry and in patients = who had=20 progressive disease during the last course of trastuzumab = containing=20 therapy. We have considered whether these results might be due to = the=20 effect of metronomic chemotherapy alone or due to a synergistic = effect of=20 the combination. In previous studies in which metronomic = chemotherapy was=20 used alone, we observed an overall response of 10% and a global = clinical=20 benefit of 32% in pre-treated patients [12,13].=20 In the present study, we observed an overall response of 18% and a = clinical benefit (RP plus RC plus SD for =E2=89=A5 24 weeks) of = 46%, confirming a=20 significant activity of the combination of metronomic chemotherapy = plus=20 trastuzumab. Treatment beyond progression represents a new = paradigm in=20 cancer therapy, although the indirect comparison of the two = studies (not=20 obtained in a randomized setting) and the nature of the present = study=20 cannot justify the extended use of trastuzumab after progression = or the=20 use of the combination of trastuzumab with metronomic chemotherapy = instead=20 of the single modalities alone. Moreover, eight patients started = the study=20 protocol after achieving clinical response to previous trastuzumab = combination therapy. The possibility that trastuzumab alone could = have=20 allowed a clinical benefit similar to that obtained with = trastuzumab plus=20 metronomic chemotherapy is reasonable.

Additional studies to test the independent contribution of = metronomic=20 chemotherapy and trastuzumab when used after disease progression = during=20 trastuzumab are warranted.

Among patients with progressive disease at study entry we = observed 2=20 objective responses and 3 cases of prolonged stabilization of = disease=20 indicating an activity in terms of clinical benefit in resistant = patients=20 (5 out of 14 patients, 36%) (Table 2).=20 Moreover, in 6 patients we registered no evidence of progressive = disease=20 for at least 24 weeks indicating that a small but relevant = fraction of=20 heavily pre-treated MBC patients can achieve long term clinical = benefit=20 with this treatment option.

Among patients in whom progressive disease was recorded during = the last=20 course of trastuzumab containing therapy (11 pts) we observed 2 PR = and 1=20 prolonged SD, for an overall clinical benefit of 27%. These = results are=20 particularly relevant since they support, in a clinical setting, = the=20 combination of metronomic low-dose cyclophosphamide and = methotrexate plus=20 trastuzumab, as a possible strategy for delaying or treating = acquired=20 resistance to trastuzumab in human breast cancer xenografts, as = previously=20 published [19],=20 although the nature of our study and the small sample size do not = allow=20 definitive conclusions on this issue.

The majority of patients (12 patients, 54.5%) of our series = were=20 pre-treated with more than 2 lines of chemotherapy (in combination = or not=20 with trastuzumab) and among these, 5 patients had previously = received 4=20 lines. The chance of obtaining a long term clinical benefit after = more=20 than 2 lines of chemotherapy in metastatic breast cancer is = usually=20 thought to be very poor, in particular for patients with HER2/neu = positive=20 MBC characterized by an aggressive disease course [23].=20 Moreover, in the present series, 9 patients had CNS involvement. = Among=20 these, 6 achieved clinical benefit. The inclusion of these = patients, for=20 whom a local treatment (radiotherapy in the majority of cases) was = also=20 planned or previously performed, was allowed due to the ability of = both=20 CTX and MTX to pass the BBB (blood-brain barrier) and to have = activity in=20 brain metastases from breast cancer [24],=20 although there are not data of efficacy with the use of low dose=20 metronomic chemotherapy.

The palliative goal of treatment in metastatic breast cancer = and the=20 achievement of symptomatic control and maintenance of quality of = life are=20 desirable treatment end points for the individual patient. Within = this=20 context the results achieved indicate that metronomic chemotherapy = in=20 combination with trastuzumab might represent a relevant additional = therapeutic tool. In fact patients with HER2/neu positive MBC, = where long=20 term treatment with trastuzumab has been demonstrated to be = feasible and=20 safe [25],=20 may benefit from combination with drugs characterized by a low = incidence=20 of toxic effects to allow the long term delivery of the = combination.

As previously mentioned, in our series toxicity was mild. The = profile=20 of side effects was in keeping with previously published data on=20 metronomic chemotherapy and included only 18% of grade >2 = leucopenia or=20 neutropenia, and only 27% of non hematologic toxicity. The = addition of=20 trastuzumab does not seem to increase the systemic toxicity and = the=20 individual tolerability. Only one patient, treated with = trastuzumab for=20 more than 1 year before the addition of CM, experienced a mild = decreased=20 of ventricular left ejection fraction (less than 10% from baseline = value)=20 and trastuzumab was interrupted.

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Abstract

Background

Methods

Results

Discussion

"=20 = src=3D"http://www.pubmedcentral.nih.gov/corehtml/pmc/pmcgifs/square.gif" = border=3D0>Conclusion

Abbreviations

Competing=20 interests

Authors'=20 contributions

Pre-publication history

References

Conclusion

Low-dose, oral cyclophosphamide and methotrexate combined with=20 trastuzumab demonstrated substantial efficacy in metastatic breast = cancer=20 and provided control of the disease (clinical benefit) in a = significant=20 proportion of patients. Although derived from a small non = randomized=20 study, our results could provide further support for the = disputable=20 approach of treating breast cancer patients with her2/neu=20 positive disease using trastuzumab- containing therapies = beyond=20 progression. Due to the theoretical background and the promising = results=20 reported in this study, the value of the combination of metronomic = chemotherapy and trastuzumab should be further explored in larger = clinical=20 trials focused on the debatable attitude to continue trastuzumab = beyond=20 progression.

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Abbreviations

CTX: cyclophosphamide

MTX: methotrexate

MBC: metastatic breast cancer

CM: cyclophosphamide + methotrexate

PR: partial remission

SD: stable disease

CNS: central nervous system

BBB (blood-brain barrier)

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Competing interests

The author(s) declare that they have no competing = interests.

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Abstract

Background

Methods

Results

Discussion

Conclusion

Abbreviations

Competing=20 interests

"=20 = src=3D"http://www.pubmedcentral.nih.gov/corehtml/pmc/pmcgifs/square.gif" = border=3D0>Authors'=20 contributions

Pre-publication history

References

Authors' contributions

LO conceived of the study, participated in design and = coordination and=20 prepare the manuscript, AC participated in the design of the study = and in=20 the data collection, RG participated in the data management, AR=20 participated in the design of the study and performed the = statistical=20 analysis, AB participated in the data collection, RT participated = in the=20 data collection, GP participated in the data management, AG = participated=20 in the study design, EP participated in the data collection, MC = conceived=20 of the study, participated in design and coordination and prepare = the=20 manuscript

All authors read and approved the final manuscript.

Institutional funding was used by each authors for study design = and=20 conduction, data collection, statistical analysis, manuscript=20 preparation

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Pre-publication history

The pre-publication history for this paper can be accessed = here:

http://www.pubmedcentral.nih.gov/redirect3.cgi?&&= ;reftype=3Dextlink&artid=3D1579231&iid=3D125940&jid=3D16&= FROM=3DArticle|Body&TO=3DExternal|Link|URI&article-id=3D1579231&a= mp;journal-id=3D16&&http://www.biomedcentral.com/1471-2407/6/225/= prepub

Acknowledgements

We thank our clinical and laboratory colleagues who have = contributed to=20 our research.

We thank Mr. W. Russell for editorial support

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Abstract

Background

Methods

Results

Discussion

Conclusion

Abbreviations

Competing=20 interests

Authors'=20 contributions

Pre-publication history

"=20 = src=3D"http://www.pubmedcentral.nih.gov/corehtml/pmc/pmcgifs/square.gif" = border=3D0>References

<= /TD>

References

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Figures and Tables

Table=20 1

Patients=20 characteristics

Table=20 2

Previous = treatments in=20 patients achieving clinical = benefit

Table=20 3

Side=20 effects

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