WITHDRAWN: New Breakthrough in Triple-Negative Breast Cancer Treatment: A Study on the Clinical Efficacy and Safety of the Combination of Carrilizumab and Apatinib in Dual-Targeted Neoadjuvant Therapy

doi:10.21203/rs.3.rs-3676354/v1

Objective To investigate the clinical efficacy and safety of dual-targeted neoadjuvant therapy combining carrilizumab with Apatinib in patients with triple-negative breast cancer.

Methods This study collected data from 76 patients with triple-negative breast cancer, confirmed as PD-L1 positive (CPS ≥ 1%) via immunohistochemistry and core needle biopsy, treated at Cangzhou Central Hospital from March 2021 to March 2022. Patients were randomly divided into a control group (n=38) and an observation group (n=38). Based on the standard AT chemotherapy regimen, the control group received treatment with the PD-1 inhibitor carrilizumab, while the observation group was treated with a combination of carrilizumab and the anti-angiogenic drug Apatinib. After completing neoadjuvant therapy, the objective response rate, major pathological response rate, pathological complete response rate, breast conservation rate, CD4⁺T lymphocyte subpopulation levels, vascular endothelial growth factor levels, and Ki-67 and PD-L1 expression were compared between the two groups.

Results After four cycles of neoadjuvant therapy, the observation group showed a superior major pathological response rate, pathological complete response rate, and elevated CD4⁺ T lymphocyte levels compared to the control group (P < 0.05). There was a significant decrease in the proportion of high Ki-67 expression in the observation group (P < 0.05), and the levels of vascular endothelial growth factor were lower than in the control group (P < 0.05). Although the breast conservation rate was relatively higher in the observation group, the difference was not significant (P > 0.05). The incidence of adverse events was similar in both groups, except for a higher rate of hand-foot syndrome in the observation group (P > 0.05).

Conclusion The dual-targeted neoadjuvant therapy for triple-negative breast cancer showed considerable clinical efficacy in reducing tumor burden and was acceptably safe.

Triple Negative Breast Cancer

PD-1 Inhibitors

Neoadjuvant Therapy

Breast-Conserving Surgery

Safety Assessment

In recent years, with improvements in living standards, changes in dietary habits, and advancements in medical care, the incidence of breast cancer has been steadily increasing, making it the most prevalent cancer among women. Triple-negative breast cancer (TNBC)^[1-4], characterized by its propensity for recurrence, metastasis, high malignancy, and unstable biological behavior, has become a focal point of interest in terms of treatment methods and prognosis. Apatinib^[5-7], an anti-tumor angiogenesis drug targeting the vascular endothelial growth factor receptor 2 (VEGFR2), has shown promising results in creating a hypoxic tumor microenvironment and reducing tumor burden. Carrilizumab ^[8], targeting the programmed death receptor 1 (PD-1), operates by disrupting the binding of PD-1 and its ligands to activate T lymphocytes, thereby inhibiting the "immune escape" phenomenon of tumor cells and achieving anti-tumor effects. Currently, there has been research on the dual-target therapy combining Apatinib and Carrilizumab for locally advanced gastric and head and neck cancers in neoadjuvant treatment, showing good efficacy and acceptable safety. However, this dual-target approach in TNBC remains limited to late-stage salvage treatment. Therefore, this study aims to assess the clinical efficacy and safety of combining Apatinib with Carrilizumab in the neoadjuvant treatment of triple-negative breast cancer.

1.1 Sample Size Estimation

A preliminary experiment was conducted prior to the study. The positive event rate in the observation group was denoted as p1, and in the control group as p2. The probability of Type I error was set at 0.05 (Zα=1.96), and the probability of Type II error at 0.1 (Zβ=1.28). The mean rates of occurrence and non-occurrence were represented as p and q, respectively. The sample size was calculated using the Zhejiang University Sample Size Calculator 4.0. This study included 76 patients with advanced triple-negative breast cancer treated at Cangzhou Central Hospital from March 2021 to March 2023.

1.2 General Information

76 patients with triple-negative breast cancer, confirmed as PD-L1 positive (CPS ≥ 1%) via immunohistochemistry and core needle biopsy, treated at Cangzhou Central Hospital from March 2021 to March 2022, were included. They were randomly divided into a control group and an observation group, each comprising 38 patients. This study was approved by the hospital's ethics committee [Ethical Approval Number: 2021-134-02(z)], and all patients signed informed consent forms. Inclusion criteria: 1) Diagnosis of triple-negative breast cancer confirmed by core needle biopsy; 2) Clinical stage II-III; 3) KPS patient score ≥ 70; 4) Complete pathological results obtained; 5) Comprehensive clinical data available; 6) No prior treatment; 7) Female patients. Exclusion criteria: 1) Patients with distant metastases; 2) Non-primary tumors; 3) Pregnant or lactating women; 4) Severe organ dysfunction precluding chemotherapy tolerance. Ethical approval for this study was obtained [Ethical Approval Number: 2021-134-02(z)], and all patients signed informed consent forms.

1.3 Methods

1.3.1 Neoadjuvant Therapy

Both the control and observation groups received PD-1 inhibitor carrilizumab injection (Manufacturer: Jiangsu Hengrui Medicine Co., Ltd.; Approval Number: National Medicine Standard S20190027; Specification: 200mg/vial) at a dose of 200mg intravenously, every 3 weeks, for a total of 12 weeks. The control group received standard treatment, while the observation group additionally received the anti-angiogenic VEGFR2 inhibitor Apatinib (Manufacturer: Jiangsu Hengrui Medicine Co., Ltd.; Approval Number: National Medicine Standard H20140103; Specification: 0.25g/tablet) orally at 250mg per dose, once daily, for 28 days per treatment cycle, for a total of 3 cycles. (Note: The standard treatment regimen was the AT chemotherapy regimen).

AT Chemotherapy Regimen: Intravenous injection of Doxorubicin Hydrochloride Liposome (Manufacturer: CSPC Ouyi Pharmaceutical Co., Ltd.; Approval Number: National Medicine Standard H20163178; Specification: 5mL:10mg) at 35mg/m², every 21 days, for a total of 4 cycles; Intravenous injection of Albumin-bound Paclitaxel (Manufacturer: Jiangsu Hengrui Medicine Co., Ltd.; Approval Number: National Medicine Standard H20183378; Specification: 100mg/vial) at 175mg/m², day 1, every 21 days, for a total of 4 cycles.

1.3.2 Surgical Treatment

Four weeks after completing neoadjuvant chemotherapy, both groups underwent surgery according to indications and contraindications for breast-conserving surgery or modified radical mastectomy. Breast-conserving surgery was chosen if the patient met the indications and had no contraindications, otherwise, modified radical mastectomy was performed. All surgeries were conducted by the same treatment team from the Thyroid and Breast Surgery Department III of Cangzhou Central Hospital.

Indications for Breast-Conserving Surgery: 1) Patient's desire for breast conservation; 2) Clinical stage I or II, T stage ≤ T2; 3) Preservation of a good breast shape postoperatively.

Contraindications for Breast-Conserving Surgery: 1) Inability to undergo postoperative whole-breast radiation; 2) Inability to achieve negative margins; 3) Diffuse malignant calcifications; 4) Refusal of breast-conserving surgery.

1.4 Outcome Measures

Four weeks after neoadjuvant chemotherapy, objective response rates, disease control rates, fasting peripheral venous blood CD4+, CD8+, and CD4+/CD8+ T lymphocyte subpopulation levels were evaluated and recorded for both groups. Fasting venous blood (4 mL) was drawn in the morning and processed for the detection of vascular endothelial growth factor (VEGF) levels and others using enzyme-linked immunosorbent assay (ELISA). Post-surgery, pathological tissue Ki-67 expression levels, PD-L1 expression levels (CPS scoring), major pathological response rate (MPR, defined as <10% residual tumor cells in postoperative specimens), pathological complete response rate (pCR, proportion of patients with complete pathological response in both primary breast cancer and regional lymph nodes), and breast conservation rate (proportion of patients undergoing breast-conserving surgery) were recorded. Treatment-related adverse events were also recorded and assessed.

1.5 Statistical Analysis

Statistical analyses were performed using SPSS software version 27.0 and the Storm Statistical Platform (https://www.medsta.cn/software). Categorical data were presented as proportions and compared across groups using the Chi-square test and Fisher's exact test. For metric data following a normal distribution in both groups, means ± standard deviations (`x±s) were used for representation, and comparisons were made using the t-test. Univariate logistic regression was employed to explore the independent influencing factors for major pathological response and complete pathological response, with P < 0.05 indicating statistical significance. Variables with P < 0.05 were subsequently included in a multivariate logistic regression analysis. A backward stepwise regression method was used to identify independent influencing factors for major pathological response and complete pathological response. Graphical representations were created using R software (version 4.3.1) and the ChiPlot website (https://www.chiplot.online/).

2.1 General Information

The baseline characteristics were comparable between the two groups of patients, with no significant statistical differences observed (P > 0.05). The results are shown in Table 1.

Table 1. Comparison of Baseline Data (n, %)

Variable	Total (n = 70)	Control Group (n = 34)	Observation Group (n = 36)	Statistic	P
Age, Mean ± SD	46.03 ± 7.34	44.49 ± 7.01	47.58 ± 7.42	t=-1.861	0.067
Size, Mean ± SD	32.94 ± 6.36	32.63 ± 7.07	33.24 ± 5.63	t=-0.415	0.680
BMI(kg/m²), Mean ± SD	23.92 ± 1.52	24.09 ± 1.47	23.74 ± 1.56	t=1.009	0.316
Time(month), Mean ± SD	15.69 ± 3.21	15.59 ± 3.51	15.79 ± 2.92	t=-0.268	0.789
Type, n (%)				χ²=0.062	0.803
Invasive lobular carcinoma	23 (30.26)	12 (31.58)	11 (28.95)
Invasive ductal carcinoma	53 (69.74)	26 (68.42)	27 (71.05)
BRCA1, n (%)				χ²=1.490	0.222
Unmutated	51 (67.11)	23 (60.53)	28 (73.68)
Mutated	25 (32.89)	15 (39.47)	10 (26.32)
HER-2, n (%)				χ²=0.054	0.817
Not Expressed	43 (56.58)	21 (55.26)	22 (57.89)
Low Expression	33 (43.42)	17 (44.74)	16 (42.11)
AR, n (%)				χ²=0.070	0.791
Negative	57 (75)	29 (76.32)	28 (73.68)
Positive	19 (25)	9 (23.68)	10 (26.32)
Grade, n (%)				χ²=0.211	0.646
Ⅱ	40 (52.63)	21 (55.26)	19 (50.00)
Ⅲ	36 (47.37)	17 (44.74)	19 (50.00)
Location, n (%)				χ²=1.943	0.163
Left	44 (57.89)	19 (50.00)	25 (65.79)
Right	32 (42.11)	19 (50.00)	13 (34.21)
Status, n (%)				χ²=0.536	0.464
Pre-menopausal	25 (32.89)	14 (36.84)	11 (28.95)
Post-menopausal	51 (67.11)	24 (63.16)	27 (71.05)
Ki 67, n (%)				χ²=0.396	0.529
Low Expression	12 (15.79)	7 (18.42)	5 (13.16)
High Expression	64 (84.21)	31 (81.58)	33 (86.84)

2.2 Evaluation of Efficacy

After receiving different neoadjuvant chemotherapy regimens, in the observation group, 9 patients achieved complete response, 18 partial response, 8 stable disease, and 3 progression, with an objective response rate of 71.1%. Postoperative pathology results indicated that 20 patients achieved pathological complete response (pCR), accounting for 52.6%, and 30 patients achieved major pathological response (MPR), accounting for 78.9%. In the control group, 6 patients achieved complete response, 14 partial response, 12 stable disease, and 4 progression, with an objective response rate of 52.6%. 11 patients reached pCR (28.9%) and 19 patients reached MPR (50%). The results showed that the pCR and MPR in the observation group were significantly higher than those in the control group (52.6% vs. 28.9%, 78.9% vs. 50%, P < 0.05), while there was no significant difference in the objective response rate between the two groups (71.1% vs. 52.6%, P > 0.05). Additionally, the breast conservation rates were not significantly different between the observation and control groups (52.6% vs. 47.4%, P > 0.05). The results are presented in Figure 1.

Univariate logistic regression analysis was performed with pCR as the outcome variable, and factors with P < 0.05 in univariate analysis were included in a multivariate analysis using a backward stepwise regression method. It was found that the expression status of Human Epidermal Growth Factor Receptor 2 (HER-2), Androgen Receptor (AR), clinical staging, and the neoadjuvant treatment regimen were independent influencing factors for pathological complete response (P < 0.05). Specifically, non-expression of HER-2, positive AR, earlier clinical staging, and choosing a dual-target regimen were more likely to achieve pCR. The results are shown in Table 2. Similarly, logistic regression analysis with MPR as the outcome variable revealed that clinical staging and the neoadjuvant treatment regimen were independent influencing factors for major pathological response (P < 0.05), as shown in Table 3.

Table 2. Univariate and Multivariate Logistic Regression Analysis with Pathological Complete Response as the Outcome

Variable	Beta	S.E	Z	OR (95%CI)	P	aBeta	aS.E	aZ	aOR (95%CI)	aP
HER-2, n (%)					0.038*					0.008*
Not Expressed				1.00 (Reference)					1.00 (Reference)
Low Expression	-1.03	0.50	-2.07	0.36 (0.14 - 0.95)	0.038*	-1.72	0.65	-2.64	0.18 (0.05 - 0.64)	0.008*
AR, n (%)					0.007*					0.007*
Negative				1.00 (Reference)					1.00 (Reference)
Positive	1.55	0.57	2.71	4.69 (1.54 - 14.34)	0.007*	1.92	0.71	2.72	6.83 (1.71 - 27.32)	0.007*
Grade, n (%)					0.009*					0.014*
Ⅱ				1.00 (Reference)					1.00 (Reference)
Ⅲ	-1.30	0.50	-2.60	0.27 (0.10 - 0.73)	0.009*	-1.50	0.61	-2.45	0.22 (0.07 - 0.74)	0.014*
Group					0.038*					0.014*
Observation Group				1.00 (Reference)					1.00 (Reference)
Control Group	-1.00	0.48	-2.08	0.37 (0.14 - 0.95)	0.038*	-1.50	0.61	-2.46	0.22 (0.07 - 0.74)	0.014*

*indicates P < 0.05

Table 3. Univariate and Multivariate Logistic Regression Analysis with Major Pathological Response as the Outcome

Variable	Beta	S.E	Z	OR (95%CI)	P	aBeta	aS.E	aZ	aOR (95%CI)	aP
Grade, n (%)					0.004*					0.004*
Ⅱ				1.00 (Reference)					1.00 (Reference)
Ⅲ	-1.50	0.52	-2.89	0.22 (0.08 - 0.62)	0.004*	-1.58	0.55	-2.88	0.21 (0.07 - 0.60)	0.004*
Group					0.010*					0.010*
Observation Group				1.00 (Reference)					1.00 (Reference)
Control Group	-1.32	0.51	-2.57	0.27 (0.10 - 0.73)	0.010*	-1.42	0.55	-2.56	0.24 (0.08 - 0.72)	0.010*

*indicates P < 0.05

2.3 Immunological Markers

There were no significant differences in the levels of T lymphocyte subpopulations between the two groups before neoadjuvant treatment. After completing neoadjuvant therapy, the levels of CD4⁺ T lymphocytes and the ratio of CD4⁺ to CD8⁺ T lymphocytes in the observation group were significantly higher than those in the control group. Concurrently, the level of CD8⁺ T cells in the observation group was significantly lower than that in the control group, with these differences being statistically significant (P < 0.05). The results are shown in Table 4.

Table 4. Comparison of T Lymphocyte Subpopulation Levels

Variable	Total (n = 76)	Group		Statistic	P
Variable	Total (n = 76)	Observation Group (n = 38)	Control Group(n = 38)	Statistic	P
CD4⁺before（%）, Mean ± SD	33.04 ± 2.41	32.91 ± 2.32	33.17 ± 2.52	t=-0.478	0.634
CD4⁺after（%）, Mean ± SD	35.33 ± 4.69	33.64 ± 3.98	37.01 ± 4.78	t=-3.339	0.001
CD8⁺before（%）, Mean ± SD	30.97 ± 2.02	31.06 ± 2.03	30.88 ± 2.04	t=0.384	0.702
CD8⁺after（%）, Mean ± SD	24.05 ± 3.44	26.67 ± 2.44	21.43 ± 1.97	t=10.294	<.001
CD4⁺/CD8⁺before, Mean ± SD	1.07 ± 0.12	1.07 ± 0.12	1.08 ± 0.12	t=-0.517	0.607
CD4⁺/CD8⁺after, Mean ± SD	1.51 ± 0.35	1.27 ± 0.17	1.75 ± 0.32	t=-8.187	<.001

2.4 Cytokines and Immunohistochemistry

Before undergoing neoadjuvant treatment, there were no significant differences in the expression levels of Ki-67 and PD-L1 between the two groups of patients. After completing neoadjuvant therapy, both groups showed a slight decrease in the proportion of patients with high PD-L1 expression, although this decrease was not significant. However, there was a significant reduction in the proportion of patients with high Ki-67 expression in the observation group. The results are shown in Table 5. This study also conducted linear regression analysis of vascular endothelial growth factor (VEGF) levels and the proportion of residual viable tumor cells (RVT) after neoadjuvant therapy. The findings revealed that the level of VEGF in the observation group was significantly lower than that in the control group after treatment, and a moderate linear relationship was observed between VEGF and RVT. The linear regression equation was: RVT (%) = 0.697 × VEGF - 83.043, with a determination coefficient R2 of 0.643. The results are presented in Figure 2.

Table 5. Distribution of PD-L1 and Ki-67 Expression Levels

Variable	Total (n = 76)	Group		Statistic	P
Variable	Total (n = 76)	Observation Group (n = 38)	Control Group(n = 38)	Statistic	P
PD-L1 before, n (%)				χ²=1.076	0.300
Low Expression（＜20%）	30 (41.67)	12 (35.29)	18 (47.37)
High Expression（≥20%）	42 (58.33)	22 (64.71)	20 (52.63)
PD-L1 after, n (%)				χ²=0.259	0.611
Low Expression（＜20%）	31 (44.29)	14 (41.18)	17 (47.22)
High Expression（≥20%）	39 (55.71)	20 (58.82)	19 (52.78)
Ki-67 before, n (%)				χ²=1.583	0.208
Low Expression（＜30%）	12 (15.79)	8 (21.05)	4 (10.53)
High Expression（≥30%）	64 (84.21)	30 (78.95)	34 (89.47)
Ki-67 after, n (%)				χ²=4.653	0.031
Low Expression（＜30%）	49 (64.47)	29 (76.32)	20 (52.63)
High Expression（≥30%）	27 (35.53)	9 (23.68)	18 (47.37)

2.5 Safety Assessment

During the course of receiving neoadjuvant therapy, both patient groups experienced adverse reactions including angiogenesis, immune pneumonitis, leukopenia, hand-foot syndrome, nausea, vomiting, rash, and itching. However, no grade 3 or higher adverse events were reported. The incidence of hand-foot syndrome in the observation group was significantly higher than that in the control group (23.68% vs 2.63%, P<0.05), while there was no significant difference in the occurrence of other adverse reactions.

Table 6. Comparison of Adverse Reactions

Adverse Reactions	Grade	Observation Group（n=38）	Control Group（n=38）	c2	P
Angiogenesis	Grade 0	24（63.16%）	23（60.53%）	0.056	0.813
	Grade Ⅰ	10（26.32%）	9（23.68%）
	Grade Ⅱ	4（10.53%）	6（15.79%）
	Grade Ⅲ	0	0
	Grade Ⅳ	0	0
Immune Pneumonia	Grade 0	29（76.32%）	30（78.95%）	0.076	0.783
	Grade Ⅰ	6（15.79%）	5（13.16%）
	Grade Ⅱ	3（7.89%）	3（7.89%）
	Grade Ⅲ	0	0
	Grade Ⅳ	0	0
Leukopenia	Grade 0	32（84.21%）	29（76.32%）	0.748	0.387
	Grade Ⅰ	4（10.53%）	5（13.16%）
	Grade Ⅱ	2（5.26%）	4（5.26%）
	Grade Ⅲ	0	0
	Grade Ⅳ	0	0
Hand-Foot Syndrome	Grade 0	29（76.32%）	37（97.37%）	7.370	0.007*
	Grade Ⅰ	4（10.53%）	1（2.63%）
	Grade Ⅱ	5（13.16%）	0
	Grade Ⅲ	0	0
	Grade Ⅳ	0	0
Nausea and Vomiting	Grade 0	24（63.16%）	26（68.42%）	0.234	0.629
	Grade Ⅰ	10（26.32%）	11（28.95%）
	Grade Ⅱ	4（10.53%）	1（2.63%）
	Grade Ⅲ	0	0
	Grade Ⅳ	0	0
Rash and Itching	Grade 0	26（68.42%）	25（65.79%）	0.060	0.807
	Grade Ⅰ	8（21.05%）	6（15.79%）
	Grade Ⅱ	4（10.53%）	7（18.42%）
	Grade Ⅲ	0	0
	Grade Ⅳ	0	0

Note: * indicates a statistically significant difference (P<0.05).

Considering the unique biological characteristics of triple-negative breast cancer (TNBC), the exploration of neoadjuvant treatment strategies has evolved from conventional chemotherapy to platinum-based regimens and recently to the emerging field of neoadjuvant immunotherapy for TNBC. The progress and deepening of research in this area are closely related to the discovery of gene mutations and molecular therapeutic targets.

Neoadjuvant Immunotherapy

PD-1/PD-L1 inhibitors initially showed promising results in salvage therapy for advanced TNBC ^[9-14]. According to the IMpassion130 study, the combination of atezolizumab and albumin-bound paclitaxel successfully extended the overall survival of patients with advanced TNBC to up to 2 years^[15]. Subsequently, as understanding grew, PD-1 inhibitors were incorporated into neoadjuvant treatment strategies. Randomized controlled trials such as KEYNOTE522, IMpassion031,and I-SPY2 ^[16] have confirmed that the addition of PD-1 inhibitors can improve the pathological complete response rate in TNBC patients, reducing tumor burden. Moreover, based on the IMpassion031 study, atezolizumab has been included in the 2023 version of the ESMO Breast Cancer Treatment Guidelines for neoadjuvant chemotherapy in early-stage TNBC.

Dual-targeted Neoadjuvant Treatment

Dual-targeted therapy combining PD-1 inhibitors with anti-angiogenesis agents has shown favorable clinical outcomes in salvage therapy for advanced TNBC, prolonging progression-free survival and overall survival, and improving long-term prognosis. Dual-targeted neoadjuvant therapy has now been used for neoadjuvant treatment in locally advanced gastric cancer and head and neck squamous cell carcinoma, achieving considerable clinical efficacy. For example, Ju Wutong et al.^[17] utilized the combination of carrelizumab and apatinib in neoadjuvant treatment for patients with locally advanced oral squamous cell carcinoma, achieving an objective response rate of 40%, with a good response observed in patients with CPS≥10%. Additionally, Xiong Hui et al. ^[18] conducted a three-arm study on dual-targeted neoadjuvant chemotherapy in locally advanced gastric cancer, demonstrating that the dual-targeted group had a significantly higher objective response rate compared to the PD-1 inhibitor group and the chemotherapy alone group (73% vs. 60% vs. 35.6%). Furthermore, it significantly improved progression-free survival, disease-free survival, and overall survival in patients with locally advanced gastric cancer, leading to a 4-year overall survival rate of 86.2%. Therefore, this study adopted dual-targeted neoadjuvant treatment for TNBC and confirmed a certain clinical efficacy.

Research Findings

n this study, a novel indicator called the major pathological response (MPR) was introduced to evaluate the efficacy of neoadjuvant chemotherapy. Compared to pathological complete response (pCR), MPR can better reflect the effectiveness of neoadjuvant chemotherapy. Additionally, the residual tumor cell proportion (RVT) can accurately reflect the changes in tumor size from pre-neoadjuvant chemotherapy to post-neoadjuvant chemotherapy and provide a quantitative assessment. Furthermore, objective response rate based on imaging evaluation is more accurate and can prevent the issue of "pseudo progression" caused by RECIST evaluation. Although pCR is relatively high in triple-negative breast cancer (TNBC) patients, MPR cannot replace pCR in evaluating the efficacy of neoadjuvant treatment. However, MPR and RVT can quantitatively represent the effectiveness of neoadjuvant treatment.

Based on logistic regression analysis, patients with HER-2 non-expression are more likely to achieve pathological complete response. This may be due to a higher proportion of T3 and T4 stages and a higher likelihood of axillary lymph node metastasis in HER-2-low TNBC patients. In addition, this study did not use targeted treatment for HER-2, so the potential benefits for HER-2-low expression group cannot be reflected.

The presence of BRCA1 mutation is an important reference for using platinum-based neoadjuvant treatment. In this study, the presence of BRCA1 mutation was not an independent influencing factor for pCR and MPR. To validate this result, RNAseq data (level 3) of TNBC and corresponding clinical information were obtained from The Cancer Genome Atlas (TCGA) database (https://portal.gdc.com). Genes in the relevant pathways were collected, and analysis was performed using the R software GSVA package with the parameter method='ssgsea'. Finally, the correlation between BRCA1 gene and pathway scores was analyzed using Spearman correlation. The results showed that there was no significant correlation between the increase in BRCA1 mutation and apoptosis and angiogenesis pathways. This indirectly confirms that BRCA1 mutation does not improve or weaken pCR and MPR through the influence on the PD-1 inhibitor carrelizumab and the anti-angiogenesis drug apatinib.

VEGF^[13,19]and RVT showed a moderate linear correlation, possibly due to the elevated levels of VEGF promoting neoangiogenesis, which to some extent avoids the tumor cell apoptosis^[20,21] caused by the anti-angiogenesis effect of apatinib, thus leading to residual tumor cells. Safety evaluation is a comprehensive evaluation endpoint for multi-drug combinations. In this study, the AT-based chemotherapy regimen was used, and the addition of dual-targeted therapy compared to monotherapy with PD-1 inhibitors significantly increased the incidence of hand-foot syndrome as an adverse event. However, it did not result in grade 3 or above adverse events, indicating that the safety of the AT-based dual-targeted treatment regimen is acceptable to a certain extent, but comprehensive pre-chemotherapy assessments should be performed.

Overall, considering the comprehensive evaluation of patients' pre-neoadjuvant treatment status, the dual-targeted neoadjuvant treatment regimen demonstrates considerable clinical efficacy and an acceptable level of safety.

Ethical Approval

The study was approved by the Ethics Committee of Cangzhou Central Hospital, and all subjects signed an informed consent form.

Consent for publication

Not applicable

Availability of data and materials

All study data were obtained with informed consent from patients.

Competing interests

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

Funding

No funding sources

Authors’ contributions

Y.Y. and X.Z. wrote the main manuscript text, Y.Y. prepared Figures,X.Z.prepared Tables. All authors reviewed the manuscript.

Acknowledgements

Thanks to Mr Xiaoyu ZAHNG for her technical support for this article; Thanks to Mr Xiaoyu ZAHNG for his outstanding contribution to this article.

DENG H, WANG L, WANG N, et al. Neoadjuvant checkpoint blockade in combination with Chemotherapy in patients with tripe-negative breast cancer: exploratory analysis of real-world, multicenter data[J]. BMC Cancer, 2023, 23(1):29.
JIANG M, SHAO B, WAN D, et al. Eribulin combined with antiangiogenic agents in women with HER2-negative metastatic breast cancer: a retrospective multicenter study[J]. Ther Adv Med Oncol, 2023, 15:17588359231204856.
LIU J, HE M, OU K, et al. Efficacy and safety of apatinib combined with dose-dense paclitaxel and carboplatin in neoadjuvant therapy for locally advanced triple-negative breast cancer: A prospective cohort study with propensity-matched analysis[J]. Int J Cancer, 2023.
LIU Y, WANG W, YIN R, et al. A phase 1 trial of fuzuloparib in combination with apatinib for advanced ovarian and triple-negative breast cancer: efficacy, safety, pharmacokinetics and germline BRCA mutation analysis[J]. BMC Med, 2023, 21(1):376.
AND ALTERNATIVE MEDICINE E C. Retracted: Efficacy, Safety, and Tumor Marker Inhibition of Apatinib Combined with Conventional Chemotherapy Regimens for Patients with Advanced Triple-Negative Breast Cancer[J]. Evid Based Complement Alternat Med, 2023, 2023:9879023.
CAO M, LU H, YAN S, et al. Apatinib plus etoposide in pretreated patients with advanced triple-negative breast cancer: a phase II trial[J]. BMC Cancer, 2023, 23(1):463.
ZHENG Y, YANG X, YAN C, et al. Effect of apatinib plus neoadjuvant chemotherapy followed by resection on pathologic response in patients with locally advanced gastric adenocarcinoma: A single-arm, open-label, phase II trial[J], 2020, 130:12–19.
ZHANG Q, SHAO B, TONG Z, et al. A phase Ib study of camrelizumab in combination with apatinib and fuzuloparib in patients with recurrent or metastatic triple-negative breast cancer[J]. BMC Med, 2022, 20(1):321.
LIU J, WANG Y, TIAN Z, et al. Multicenter phase II trial of Camrelizumab combined with Apatinib and Eribulin in heavily pretreated patients with advanced triple-negative breast cancer[J]. Nat Commun, 2022, 13(1):3011.
LIU S, ZHANG L, YE W, et al. Apatinib potentiates the therapeutic effect of anti-PD-1 in locally advanced head and neck cancers[J]. Oral Dis, 2023.
LIU Z, WANG X, WANG J, et al. The efficacies and biomarker investigations of antiangiogenic agents and PD-1 inhibitors for metastatic soft tissue sarcoma: A multicenter retrospective study[J]. Front Oncol, 2023, 13:1124517.
WANG C, WANG Z, ZHAO Y, et al. Neoadjuvant PD-1 Inhibitor Plus Apatinib and Chemotherapy Versus Apatinib Plus Chemotherapy in Treating Patients With Locally Advanced Gastric Cancer: A Prospective, Cohort Study[J]. J Gastric Cancer, 2023, 23(2):328–339.
WANG Q, GAO J, DI W, et al. Anti-angiogenesis therapy overcomes the innate resistance to PD-1/PD-L1 blockade in VEGFA-overexpressed mouse tumor models[J]. Cancer Immunol Immunother, 2020, 69(9):1781–1799.
XU C, XIE X, KANG N, et al. Neoadjuvant PD-1 inhibitor and apatinib combined with S-1 plus oxaliplatin for locally advanced gastric cancer patients: a multicentered, prospective, cohort study[J]. J Cancer Res Clin Oncol, 2023, 149(7):4091–4099.
ADAMS S, DIéRAS V, BARRIOS C, et al. Patient-reported outcomes from the phase III IMpassion130 trial of atezolizumab plus nab-paclitaxel in metastatic triple-negative breast cancer[J]. Annals of Oncology, 2020, 31(5):582–589.
RIZZO A, CUSMAI A, ACQUAFREDDA S, et al. KEYNOTE-522, IMpassion031 and GeparNUEVO: changing the paradigm of neoadjuvant immune checkpoint inhibitors in early triple-negative breast cancer[J]. Future Oncol, 2022, 18(18):2301–2309.
JU W T, XIA R H, ZHU D W, et al. A pilot study of neoadjuvant combination of anti-PD-1 camrelizumab and VEGFR2 inhibitor apatinib for locally advanced resectable oral squamous cell carcinoma[J]. Nat Commun, 2022, 13(1):5378.
XIONG H, LI Y. Neoadjuvant PD-1 inhibitor plus apatinib and chemotherapy versus apatinib plus chemotherapy versus chemotherapy alone in patients with locally advanced gastric cancer[J]. Am J Cancer Res, 2023, 13(8):3559–3570.
MINOVES M, HAZANE-PUCH F, MORIONDO G, et al. Differential Impact of Intermittent vs. Sustained Hypoxia on HIF-1, VEGF and Proliferation of HepG2 Cells[J]. Int J Mol Sci, 2023, 24(8).
DZHALILOVA D S, MAKAROVA O V. HIF-Dependent Mechanisms of Relationship between Hypoxia Tolerance and Tumor Development[J]. Biochemistry (Mosc), 2021, 86(10):1163–1180.
YOU L, WU W, WANG X, et al. The role of hypoxia-inducible factor 1 in tumor immune evasion[J]. Med Res Rev, 2021, 41(3):1622–1643.

No competing interests reported.

WITHDRAWN: New Breakthrough in Triple-Negative Breast Cancer Treatment: A Study on the Clinical Efficacy and Safety of the Combination of Carrilizumab and Apatinib in Dual-Targeted Neoadjuvant Therapy

Status:

Version 1

Editorial Note

Abstract

Figures

Introduction

1. Materials and Methods

2. Results

3. Discussion

Declarations

References

Additional Declarations

Status:

Version 1