Mahtani, R. L.

Abstract Introduction: Metaplastic breast cancer (MpBC) is a rare and histologically diverse subtype of breast cancer (BC) that is frequently triple negative (TN) and exhibits poor responsiveness to chemotherapy (CT). Our group previously reported a low pathologic complete response (pCR) rate among patients (pts) with MpBC treated with neoadjuvant CT in the pre-immunotherapy (IO) era. The standard neoadjuvant approach for pts with stage 2-3 TNBC has evolved with the results of the KEYNOTE-522 (KN522) trial, which demonstrated improved pCR rates, event-free survival (EFS), and overall survival (OS) with the addition of pembrolizumab to CT. However, pts with MpBC were not well-represented in KN522, and their response to IO remains poorly characterized. In this study, we examine the pCR rate with the addition of IO to neoadjuvant CT in pts with TN MpBC. Methods: Pts diagnosed with MpBC and treated at Miami Cancer Institute between 2017-2024 were retrospectively identified by COTA real-world Analytics® platform following IRB approval. Eligible pts had stage 2-3 ER-negative (defined as ER < 10%), PR-negative, HER2-negative MpBC, received neoadjuvant systemic therapy, and subsequently underwent definitive surgery. Demographic, clinical, treatment and outcome data were extracted from the electronic health record. pCR was defined as the absence of residual invasive cancer in the breast and axillary lymph nodes at the time of surgery. Kaplan-Meier method was used to estimate median disease-free survival (mDFS) and median OS (mOS). Comparison between treatment groups for pCR were performed using Fisher’s exact test. No multivariable or survival modeling was performed due to limited statistical power in this small cohort. All p values were two-sided. Results: A total of 27 pts were included in the analysis; 16 pts received CT (in the pre-IO era) with 19.2 months (m) median follow up and 11 pts received CT + IO with 15.5m median follow up. Spindle cell histology was reported in 18.5% of tumors, non-spindle cell in 59.3% and 22.2% were not further specified. Most patients (81.5%) had clinical stage 2 disease, 18.5% had stage 3; median tumor size was 3.2 cm. Anthracycline-based CT was administered to 81.5% of pts, and the remainder received non-anthracycline regimens. pCR was achieved in none of the 16 pts (0.0%) who received CT alone and in 3 of 11 pts (27.3%) who received CT + IO (p=0.046). Among the 3 pts who achieved pCR, 2 had non-spindle cell histology and 1 unspecified. All 3 pCR pts had stage 2 disease, received IO and anthracycline, and experienced immune-related adverse events. mDFS was 23.9m in the CT group and 14.6 m in the CT + IO group (p = 0.641), though follow-up duration differed between groups. Among all pts, mDFS was 15.3 m in those who did not achieve pCR and was not reached in those that did (p = 0.226). mOS was not reached in the CT group and was 20.7m in the CT + IO group (p = 0.192). Conclusion: In this small, retrospective real-world analysis of pts with early-stage TN MpBC, the addition of IO to neoadjuvant CT was associated with a higher pCR rate compared to CT alone. Although the observed pCR rate of 27.3% with CT+IO is lower than that reported in KN522 for unselected TNBC, this likely reflects the small sample size and the inherently CT-resistant biology of MpBC. None of the pts in the CT alone group achieved pCR, suggesting that IO may help to overcome CT resistance in MpBC. Differences in mDFS and mOS were not statistically significant, possibly due to limited follow up and sample size. Despite these limitations, our findings highlight the importance of incorporating IO into treatment for MpBC. Future multicenter analyses are ongoing to validate these results in a larger, more diverse population and to further explore the role of histologic subtypes and immune biomarkers in predicting response. Citation Format: N. Dempsey, L. Hodgson, A. Sandoval-Leon, L. Carcas, M. Ahluwalia, C. Wang, H. Kim, P. Advani, R. Mahtani. Pathologic complete response rates in early-stage triple negative metaplastic breast cancer in the neoadjuvant immunotherapy era: a retrospective review [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PS4-10-07.

Abstract Background: Hispanic/Latinx (HL) and African American (AA) breast cancer (BC) patients (pts) have increased prevalence of high-risk features such as incidence of BC at age <50 and estrogen receptor negativity. We previously showed that AA and HL had a lower fraction of neutrophils and M2 macrophages (Mɸ) despite higher percentage of PD-L1 positive cases. This study aims to further characterize differences in the tumor immune microenvironment between racial and ethnic groups, with a focus on how these differences vary by site of biopsy. Methods: We analyzed 19,459 BC samples tested by NGS (592, NextSeq; WES, NovaSeq) and WTS (NovaSeq; Caris Life Sciences). Race/ethnicity data were self-reported by pts. Immune cell proportions were estimated using WTS deconvolution (Quantiseq). Gene expression was analyzed for T-cell inflammed score (TIS), MAPK Activation Score (MPAS) and interferon-gamma (IFNy) score. Real-world overall survival (OS) data were derived from insurance claims, calculated from tissue collection or treatment initiation to last contact, and analyzed using Kaplan-Meier. Statistical significance was assessed by chi-square and Mann-Whitney U test with p-values adjusted for multiple comparisons (q<0.05). Results: There were 9674 Non-Hispanic Whites (NHW) (primary BC, defined as biopsy (bx) from breast) pBC: n=3,537, 36.6%; (metastatic BC, defined as biopsy outside of the breast) mBC: n=6,137 63.4%, 1800 AA (pBC: n=750, 42%, mBC: n=1,050, 58%), and 1795 HL (pBC: n=842, 47%; mBC n=953, 53%) samples. There were 2364 TNBC (66% NHW, 19% NHB, 15% HL), 4318 HR+/HER2- (76% NHW, 11.6% NHB, 12.4% HL), and 893 HER2+ (68% NHW, 15% NHB, 17% HL). In pBC overall, AA had lower median cell fraction (%) of B cells (4.8% vs 5.3%), M2 Mɸ (3.4% vs 4.4%), but higher median cell fraction of dendritic cells (DC) (2.8% vs 2.6%) compared to NHW while HL had lower median cell fraction of M2 Mɸ (3.9% vs 4.4%) and higher median cell fraction of CD8+ T cell (0.4% vs 0.2%), all q<0.05. In pBC, HL had higher IFNy score (-0.3 vs -0.34), while AA had lower MPAS (-1.2 vs -0.96), all q<0.05. In lymph node bx, AA had lower median % of M2 Mɸ (3.4% vs 4.4%, q<0.05). No significant differences were seen in the liver bx by race but notably there were lower median cell fractions of CD4+, CD8+, and regulatory T cells (0.0 across NHW, AA, HL) across all race/ethnicities vs. other biopsy sites. By subtype, TNBC primary bx yielded much of the significant changes with AA having lower median cell fraction of M2 Mɸ (2.49% vs 3.04%, q= 0.01) compared to NHW. In primary bx, AA (35.6 m vs 48.5 m, HR 1.4, 95% CI 1.2-1.5, p<0.001) and HL (42.4 m vs 48.5 m, HR 1.2, 95% CI 1.1-1.4, p<0.001) had worse median OS versus NHW. In lymph node bx, AA also had worse OS (29.2 m vs 37.2 m, HR 1.2, 95% CI 1-1.5, p=0.03) compared to NHW. In liver bx, there was worse mOS overall but no difference by race (NHW 18.65m, AA 18.79m, HL 20.6m, p =0.73). In HR+/HER2- liver bx AA had worse OS (14.2 m vs 20.9 m, HR 1.3, 95% CI 1-1.7, p=0.03) versus NHW. In HER2+ primary bx, HL had worse OS (43.2m vs 66.9m, HR 1.7, 95% CI 1.1-2.6, p=0.009). There was a trend towards worse mOS in TNBC AA patients receiving pembrolizumab (18.42m vs HL 23.69m vs NHW 35.30m; p=0.16) and HER2+ AA patients receiving trastuzumab deruxtecan (AA: 16.06m vs HL: 26.81m vs NHW: not reached; p = 0.05). Conclusions: We found race and biopsy site specific differences in the breast cancer immune microenvironment. AA pts had lower M2 Mɸ in primary and lymph node bx while NHW pts showed higher CD8+ T cell in primary tumors. Liver biopsies exhibited low T cell infiltration across all groups. AA pts had worse mOS in primary and lymph node bx compared to NHW but not in liver bx of which we saw worse mOS in all races. These results highlight the need to consider both race and bx site in treatment decisions. Citation Format: R. Hsu, S. Deshmukh, N. Gyabaah-Kessie, E. Rallos, B. Al-Zubeidy, E. Gonzalez, A. G. Baugh, S. Carrel, M. Li, D. Zavala, A. Martynova, P. Jayachandran, D. Stewart, D. Spicer, S. Wu, J. Xiu, G. W. Sledge Jr., R. L. Mahtani, A. C. Sandoval Leon, S. Gandhi, S. Chumsri, M. Lustberg, M. C. Stern, E. T. Roussos Torres. Immune microenvironment and survival differences among Hispanic and African American breast cancer cases by biopsy site [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PS3-12-06.