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Fohlin H, Nordenskjöld A, Rosell J, Fernö M, Fornander T, Rydén L, Skoog L, Nordenskjöld B, Stål O. Breast cancer hormone receptor levels and benefit from adjuvant tamoxifen in a randomized trial with long-term follow-up. Acta Oncol 2024; 63:535-541. [PMID: 38967128 PMCID: PMC11332493 DOI: 10.2340/1651-226x.2024.40493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/21/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Hormone receptor positivity predicts benefit from endocrine therapy but the knowledge about the long-term survival of patients with different tumor receptor levels is limited. In this study, we describe the 25 years outcome of tamoxifen (TAM) treated patients. PATIENTS AND METHODS Between 1983 and 1992, a total of 4,610 postmenopausal patients with early-stage breast cancer were randomized to receive totally 2 or 5 years of TAM therapy. After 2 years, 4,124 were alive and free of breast cancer recurrence. Among these, 2,481 had demonstrated estrogen receptor positive (ER+) disease. From 1988, the Abbot enzyme immunoassay became available and provided quantitative receptor levels for 1,210 patients, for which our analyses were done. RESULTS After 5 years of follow-up, when all TAM treatment was finished, until 15 years of follow-up, breast cancer mortality for patients with ER+ disease was significantly reduced in the 5-year group as compared with the 2-year group (hazard ratios [HR] 0.67, 95% confidence intervals [CI] 0.55-0.83, p < 0.001). After 15 years, the difference between the groups remained but did not increase further. A substantial benefit from prolonged TAM therapy was only observed for the subgroup of patients with ER levels below the median (HR = 0.62, 95% CI 0.46-0.84, p = 0.002). Similarly, patients with progesterone receptor negative (PR-) disease did benefit from prolonged TAM treatment. For patients with progesterone receptor positive (PR+) disease, there was no statistically significant benefit from more than 2 years of TAM. Interpretation: As compared with 2 years of adjuvant TAM, 5 years significantly prolonged breast cancer-specific survival. The benefit from prolonged TAM therapy was statistically significant for patients with ER levels below median or PR-negative disease. There was no evident benefit from prolonged TAM for patients with high ER levels or with PR+ tumors.
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Affiliation(s)
- Helena Fohlin
- Regional Cancer Center South-East Sweden and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Anna Nordenskjöld
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg Sweden
| | - Johan Rosell
- Regional Cancer Center South-East Sweden and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Mårten Fernö
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Tommy Fornander
- Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden
| | - Lisa Rydén
- Department of Clinical Sciences Lund, Division of Surgery, Lund University, Lund, Sweden
| | - Lambert Skoog
- Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden
| | - Bo Nordenskjöld
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Olle Stål
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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2
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Jiang H, Zhong J, Wang J, Song G, Di L, Shao B, Zhang R, Liu Y, Zhu A, Wang N, Li H. Abemaciclib plus endocrine therapy versus chemotherapy after progression on prior palbociclib in HR+/HER2- metastatic breast cancer: A single center real-world study in China. Cancer Med 2024; 13:e7249. [PMID: 38770648 PMCID: PMC11106689 DOI: 10.1002/cam4.7249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 04/19/2024] [Accepted: 04/28/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Cyclin-dependent kinase (CDK) 4/6 inhibitor plus endocrine therapy (ET) become standard-of-care for patients with hormone receptor-positive, human epidermal growth factor receptor-2 negative (HR+/HER2-) metastatic breast cancer (MBC). However, the optimal therapeutic paradigm after progression on CDK4/6 inhibitor remains unclear. This study aimed to evaluate the efficacy and safety of abemaciclib with switching ET versus chemotherapy after progression on prior palbociclib-based ET in Chinese patients with HR+/HER2- MBC. METHODS From 414 consecutive patients with HR+/HER2- MBC who had been treated with palbociclib plus ET from September 2018 to May 2022 in Peking University Cancer Hospital, we identified 80 patients who received abemaciclib plus switching ET or chemotherapy after progression on palbociclib, matched for age, original stage at diagnosis, disease-free interval, and tumor burden at 1:1 ratio. The primary endpoint was progression-free survival (PFS) compared using the Kaplan-Meier method. A Cox proportional hazard model was performed to identify clinical factors associated with PFS in the abemaciclib group. RESULTS The median PFS was 6.0 months (95% confidence interval [CI]: 3.94-8.06) in abemaciclib group and 4.0 months (95% CI, 2.52-5.49) in chemotherapy group (p = 0.667). And, there was no difference in median PFS between the sequential and nonsequential arm (6.0 vs. 6.0 months) in the abemaciclib group though fewer lines of prior systemic therapy and longer PFS from prior palbociclib in the sequential arm. However, patients with prior palbociclib as the first-line therapy had a significantly longer median PFS versus prior palbociclib as ≥2nd-line therapy (11.0 vs. 5.0 months, p = 0.043). Based on multivariable analysis, ER+/PR+ was an independent factor associated with longer PFS. There was no significant difference in overall survival between the abemaciclib and chemotherapy groups (p = 0.069). CONCLUSION Our findings indicate that abemaciclib plus switching ET might be one of feasible treatment options for Chinese patients with HR+/HER2- MBC after progression on prior palbociclib-based therapy in addition to chemotherapy.
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Affiliation(s)
- Hanfang Jiang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Breast OncologyPeking University Cancer Hospital & InstituteBeijingChina
| | - Jianxin Zhong
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Breast OncologyPeking University Cancer Hospital & InstituteBeijingChina
| | - Jing Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Breast OncologyPeking University Cancer Hospital & InstituteBeijingChina
| | - Guohong Song
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Breast OncologyPeking University Cancer Hospital & InstituteBeijingChina
| | - Lijun Di
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Breast OncologyPeking University Cancer Hospital & InstituteBeijingChina
| | - Bin Shao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Breast OncologyPeking University Cancer Hospital & InstituteBeijingChina
| | - Ruyan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Breast OncologyPeking University Cancer Hospital & InstituteBeijingChina
| | - Yaxin Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Breast OncologyPeking University Cancer Hospital & InstituteBeijingChina
| | - Anjie Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Breast OncologyPeking University Cancer Hospital & InstituteBeijingChina
| | - Nan Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Breast OncologyPeking University Cancer Hospital & InstituteBeijingChina
| | - Huiping Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Breast OncologyPeking University Cancer Hospital & InstituteBeijingChina
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3
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Tjan-Heijnen VC, Lammers SW, Geurts SM, Vriens IJ, Swinkels AC, Smorenburg CH, van der Sangen MJ, Kroep JR, de Graaf H, Honkoop AH, Erdkamp FL, de Roos WK, Linn SC, Imholz AL. Extended adjuvant aromatase inhibition after sequential endocrine therapy in postmenopausal women with breast cancer: follow-up analysis of the randomised phase 3 DATA trial. EClinicalMedicine 2023; 58:101901. [PMID: 36992863 PMCID: PMC10041456 DOI: 10.1016/j.eclinm.2023.101901] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 03/28/2023] Open
Abstract
Background The DATA study evaluated the use of two different durations of anastrozole in patients with hormone receptor-positive breast cancer who were disease-free after 2–3 years of tamoxifen. We hereby present the follow-up analysis, which was performed after all patients reached a minimum follow-up of 10 years beyond treatment divergence. Methods The open-label, randomised, phase 3 DATA study was performed in 79 hospitals in the Netherlands (ClinicalTrials.gov, number NCT00301457). Postmenopausal women with hormone receptor-positive breast cancer who were disease-free after 2–3 years of adjuvant tamoxifen treatment were assigned to either 3 or 6 years of anastrozole (1 mg orally once a day). Randomisation (1:1) was stratified by hormone receptor status, nodal status, HER2 status, and prior tamoxifen duration. The primary outcome was adapted disease-free survival, defined as disease-free survival from 3 years after randomisation onwards. Adapted overall survival was assessed as a secondary outcome. Analyses were performed according to the intention-to-treat design. Findings Between June 28, 2006, and August 10, 2009, 1912 patients were randomly assigned to 3 years (n = 955) or 6 years (n = 957) of anastrozole. Of these, 1660 patients were eligible and disease-free at 3 years after randomisation. The 10-year adapted disease-free survival was 69.2% (95% CI 55.8–72.3) in the 6-year group (n = 827) and 66.0% (95% CI 62.5–69.2) in the 3-year group (n = 833) (hazard ratio (HR) 0.86; 95% CI 0.72–1.01; p = 0.073). The 10-year adapted overall survival was 80.9% (95% CI 77.9–83.5) in the 6-year group and 79.2% (95% CI 76.2–81.9) in the 3-year group (HR 0.93; 95% CI 0.75–1.16; p = 0.53). Interpretation Extended aromatase inhibition beyond 5 years of sequential endocrine therapy did not improve the adapted disease-free survival and adapted overall survival of postmenopausal women with hormone receptor-positive breast cancer. Funding AstraZeneca.
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Affiliation(s)
- Vivianne C.G. Tjan-Heijnen
- Department of Medical Oncology, Maastricht University Medical Centre, GROW, Maastricht University, Maastricht, the Netherlands
- Corresponding author. Department of Medical Oncology, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands.
| | - Senna W.M. Lammers
- Department of Medical Oncology, Maastricht University Medical Centre, GROW, Maastricht University, Maastricht, the Netherlands
| | - Sandra M.E. Geurts
- Department of Medical Oncology, Maastricht University Medical Centre, GROW, Maastricht University, Maastricht, the Netherlands
| | - Ingeborg J.H. Vriens
- Department of Medical Oncology, Maastricht University Medical Centre, GROW, Maastricht University, Maastricht, the Netherlands
| | - Astrid C.P. Swinkels
- Clinical Research Department, Netherlands Comprehensive Cancer Organisation (IKNL), Nijmegen, the Netherlands
| | - Carolien H. Smorenburg
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Judith R. Kroep
- Department of Medical Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Hiltje de Graaf
- Department of Medical Oncology, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Aafke H. Honkoop
- Department of Medical Oncology, Isala Clinics, Zwolle, the Netherlands
| | - Frans L.G. Erdkamp
- Department of Medical Oncology, Zuyderland Medical Centre Heerlen-Sittard-Geleen, Location Sittard-Geleen, Geleen, the Netherlands
| | | | - Sabine C. Linn
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Pathology, University Medical Centre Utrecht, Utrecht, the Netherlands
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4
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Development and validation of a nomogram for predicting survival of breast cancer patients with ipsilateral supraclavicular lymph node metastasis. Chin Med J (Engl) 2021; 134:2692-2699. [PMID: 34743149 PMCID: PMC8631408 DOI: 10.1097/cm9.0000000000001755] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Breast cancer patients with ipsilateral supraclavicular lymph node metastasis (ISLNM) but without distant metastasis are considered to have a poor prognosis. This study aimed to develop a nomogram to predict the overall survival (OS) of breast cancer patients with ISLNM but without distant metastasis. Methods: Medical records of breast cancer patients who received surgical treatment at the Affiliated Cancer Hospital of Zhengzhou University, Jiyuan People's Hospital and Huaxian People's Hospital between December 21, 2012 and June 30, 2020 were reviewed retrospectively. Overall, 345 patients with pathologically confirmed ISLNM and without evidence of distant metastasis were identified. They were further randomized 2:1 and divided into training (n = 231) and validation (n = 114) cohorts. A nomogram to predict the probability of OS was constructed based on clinicopathologic variables identified by the univariable and multivariable analyses. The predictive accuracy and discriminative ability were measured by calibration plots, concordance index (C-index), and risk group stratification. Results: Univariable analysis showed that estrogen receptor-positive (ER+), progesterone receptor-positive (PR+), human epidermal growth factor receptor 2-positive (HER2+) with Herceptin treatment, and a low axillary lymph node ratio (ALNR) were prognostic factors for better OS. PR+, HER2+ with Herceptin treatment, and a low ALNR remained independent prognostic factors for better OS on multivariable analysis. These variables were incorporated into a nomogram to predict the 1-, 3-, and 5-year OS of breast cancer patients with ISLNM. The C-indexes of the nomogram were 0.737 (95% confidence interval [CI]: 0.660–0.813) and 0.759 (95% CI: 0.636–0.881) for the training and the validation cohorts, respectively. The calibration plots presented excellent agreement between the nomogram prediction and actual observation for 3 and 5 years, but not 1 year, OS in both the cohorts. The nomogram was also able to stratify patients into different risk groups. Conclusions: In this study, we established and validated a novel nomogram for predicting survival of patients with ISLNM. This nomogram may, to some extent, allow clinicians to more accurately estimate prognosis and to make personalized therapeutic decisions for individual patients with ISLNM.
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5
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Gouri A, Benarba B, Dekaken A, Aoures H, Benharkat S. Prediction of Late Recurrence and Distant Metastasis in Early-stage Breast Cancer: Overview of Current and Emerging Biomarkers. Curr Drug Targets 2021; 21:1008-1025. [PMID: 32164510 DOI: 10.2174/1389450121666200312105908] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/08/2020] [Accepted: 01/14/2020] [Indexed: 12/13/2022]
Abstract
Recently, a significant number of breast cancer (BC) patients have been diagnosed at an early stage. It is therefore critical to accurately predict the risk of recurrence and distant metastasis for better management of BC in this setting. Clinicopathologic patterns, particularly lymph node status, tumor size, and hormonal receptor status are routinely used to identify women at increased risk of recurrence. However, these factors have limitations regarding their predictive ability for late metastasis risk in patients with early BC. Emerging molecular signatures using gene expression-based approaches have improved the prognostic and predictive accuracy for this indication. However, the use of their based-scores for risk assessment has provided contradictory findings. Therefore, developing and using newly emerged alternative predictive and prognostic biomarkers for identifying patients at high- and low-risk is of great importance. The present review discusses some serum biomarkers and multigene profiling scores for predicting late recurrence and distant metastasis in early-stage BC based on recently published studies and clinical trials.
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Affiliation(s)
- A Gouri
- Laboratory of Medical Biochemistry, Faculty of Medicine, University of Annaba, Algeria
| | - B Benarba
- Laboratory Research on Biological Systems and Geomatics, Faculty of Nature and Life Sciences, University of Mascara, Algeria
| | - A Dekaken
- Department of Internal Medicine, El Okbi Public Hospital, Guelma, Algeria
| | - H Aoures
- Department of Gynecology and Obstetrics, EHS El Bouni, Annaba, Algeria
| | - S Benharkat
- Laboratory of Medical Biochemistry, Faculty of Medicine, University of Annaba, Algeria
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6
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Rydén L, Loman N, Larsson C, Hegardt C, Vallon-Christersson J, Malmberg M, Lindman H, Ehinger A, Saal LH, Borg Å. Minimizing inequality in access to precision medicine in breast cancer by real-time population-based molecular analysis in the SCAN-B initiative. Br J Surg 2018; 105:e158-e168. [PMID: 29341157 PMCID: PMC5817401 DOI: 10.1002/bjs.10741] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 09/30/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Selection of systemic therapy for primary breast cancer is currently based on clinical biomarkers along with stage. Novel genomic tests are continuously being introduced as more precise tools for guidance of therapy, although they are often developed for specific patient subgroups. The Sweden Cancerome Analysis Network - Breast (SCAN-B) initiative aims to include all patients with breast cancer for tumour genomic analysis, and to deliver molecular subtype and mutational data back to the treating physician. METHODS An infrastructure for collection of blood and fresh tumour tissue from all patients newly diagnosed with breast cancer was set up in 2010, initially including seven hospitals within the southern Sweden regional catchment area, which has 1.8 million inhabitants. Inclusion of patients was implemented into routine clinical care, with collection of tumour tissue at local pathology departments for transport to the central laboratory, where routines for rapid sample processing, RNA sequencing and biomarker reporting were developed. RESULTS More than 10 000 patients from nine hospitals have currently consented to inclusion in SCAN-B with high (90 per cent) inclusion rates from both university and secondary hospitals. Tumour samples and successful RNA sequencing are being obtained from more than 70 per cent of patients, showing excellent representation compared with the national quality registry as a truly population-based cohort. Molecular biomarker reports can be delivered to multidisciplinary conferences within 1 week. CONCLUSION Population-based collection of fresh tumour tissue is feasible given a decisive joint effort between academia and collaborative healthcare groups, and with governmental support. An infrastructure for genomic analysis and prompt data output paves the way for novel systemic therapy for patients from all hospitals, irrespective of size and location.
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Affiliation(s)
- L Rydén
- Department of Clinical Sciences Lund, Surgery, Lund University, Lund, Sweden.,Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - N Loman
- Department of Clinical Sciences Lund, Oncology and Pathology, Lund University, Lund, Sweden.,Department of Haematology, Oncology and Radiotherapy, Skåne University Hospital, Lund, Sweden
| | - C Larsson
- Department of Laboratory Medicine Lund, Translational Cancer Research, Lund University, Lund, Sweden
| | - C Hegardt
- Department of Clinical Sciences Lund, Oncology and Pathology, Lund University, Lund, Sweden
| | - J Vallon-Christersson
- Department of Clinical Sciences Lund, Oncology and Pathology, Lund University, Lund, Sweden
| | - M Malmberg
- Department of Clinical Sciences Lund, Oncology and Pathology, Lund University, Lund, Sweden.,Department of Haematology, Oncology and Radiotherapy, Skåne University Hospital, Lund, Sweden
| | - H Lindman
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - A Ehinger
- Department of Clinical Sciences Lund, Oncology and Pathology, Lund University, Lund, Sweden.,Department of Pathology and Cytology, Medicinsk Service, Skåne University Hospital, Lund, Sweden
| | - L H Saal
- Department of Clinical Sciences Lund, Oncology and Pathology, Lund University, Lund, Sweden
| | - Å Borg
- Department of Clinical Sciences Lund, Oncology and Pathology, Lund University, Lund, Sweden
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7
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Gilam A, Shai A, Ashkenazi I, Sarid LA, Drobot A, Bickel A, Shomron N. MicroRNA regulation of progesterone receptor in breast cancer. Oncotarget 2018; 8:25963-25976. [PMID: 28404930 PMCID: PMC5432230 DOI: 10.18632/oncotarget.15657] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/25/2017] [Indexed: 11/25/2022] Open
Abstract
Hormone receptor status is of significant value when deciding on anti-estrogenic adjuvant therapy for breast cancer tumors. However, while estrogen receptor (ER) regulation was intensively studied, the regulation of progesterone receptor (PR) levels has not been extensively investigated. MicroRNAs (miRNAs, miRs) are post-transcriptional negative regulators of gene expression involved in diverse cellular processes. The aim of this study was to identify miRNAs that regulate PR in breast cancer.We mapped potential miRNA binding sites for miR-181a, miR-23a and miR-26b on PR mRNA and demonstrated a direct regulation of PR by these three miRNAs by in-vitro Luciferase binding assays. Over-expression of each miRNA in MCF-7 cells resulted in a reduction in the expression levels of PR mRNA. Then, expression levels of these miRNAs were measured in Formalin-Fixed, Paraffin-Embedded (FFPE) samples of 29 ER-positive breast cancer tumors and adjacent normal breast tissues. A significant reciprocal correlation between PR mRNA and the miRNA levels were identified suggesting a role for miR-181a, miR-23a and miR-26b in PR regulation in breast cancer. Moreover, the average expression fold-changes of the three miRNAs between cancerous and normal tissues displayed an opposite trend when analyzing according to Immuno-histochemistry(IHC) status. Furthermore, miR-181a and miR-26b were found to be over-expressed in most tumor tissues supporting their role in ER-positive breast cancer development. We conclude that miR-181a, miR-23a and miR-26b act as negative regulators of PR expression in ER-positive breast cancer. The diagnostic and prognostic potential of these miRNAs in breast cancer should be further evaluated.
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Affiliation(s)
- Avital Gilam
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ayelet Shai
- Oncology Department, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine, Bar Illan University, Zefad, Israel
| | | | - Liat Appel Sarid
- Oncology Department, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine, Bar Illan University, Zefad, Israel
| | - Assi Drobot
- Oncology Department, Galilee Medical Center, Nahariya, Israel
| | - Amitai Bickel
- Oncology Department, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine, Bar Illan University, Zefad, Israel
| | - Noam Shomron
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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8
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Abstract
There is a global mandate even in countries with low resources to improve the accuracy of testing biomarkers in breast cancer viz. oestrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2neu) given their critical impact in the management of patients. The steps taken include compulsory participation in an external quality assurance (EQA) programme, centralized testing, and regular performance audits for laboratories. This review addresses the status of ER/PR and HER2neu testing in India and possible reasons for the delay in development of guidelines and mandate for testing in the country. The chief cause of erroneous ER and PR testing in India continues to be easily correctable issues such as fixation and antigen retrieval, while for HER2neu testing, it is the use of low-cost non-validated antibodies and interpretative errors. These deficiencies can however, be rectified by (i) distributing the accountability and responsibility to surgeons and oncologist, (ii) certification of centres for testing in oncology, and (iii) initiation of a national EQA system (EQAS) programme that will help with economical solutions and identifying the centres of excellence and instill a system for reprimand of poorly performing laboratories.
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Affiliation(s)
- Tanuja Shet
- Department of Histopathology, Tata Memorial Centre, Mumbai, India
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9
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Hill DA, Barry M, Wiggins C, Nibbe A, Royce M, Prossnitz E, Lomo L. Estrogen receptor quantitative measures and breast cancer survival. Breast Cancer Res Treat 2017; 166:855-864. [PMID: 28825224 DOI: 10.1007/s10549-017-4439-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 08/03/2017] [Indexed: 01/13/2023]
Abstract
PURPOSE While the estrogen receptor (ER) is the single most widely used biomarker to evaluate breast cancer outcomes, aspects of ER marker biology remain poorly understood. We sought to determine whether quantitative measures of ER, such as protein expression and intensity, were associated with survival, or with survival disparities experienced by Hispanic women. METHODS A case-cohort study included a 15% random sample of invasive breast cancer cases diagnosed from 1997 to 2009 in six New Mexico counties and all deaths due to breast cancer-related causes. Pathology reports and tissue microarrays served as sources of ER information. Analyses were restricted to women with ≥1% ER immunohistochemical staining. Hazard ratios (HR) and 95% confidence intervals (CI) for breast cancer death were estimated using Cox proportional hazards models. RESULTS Included women represented 4336 ER+ breast cancer cases and 448 deaths. Median follow-up was 93 months. ER percent expression was not associated with breast cancer survival after adjustment for standard prognostic factors (p trend = 0.76). ER intensity remained a strong and independent risk factor for breast cancer survival in multivariate analyses: Women whose tumors expressed ER at intensity = 2 (HR 0.6; 95% CI 0.4-1.0) or 3 (HR 0.5; 95% CI 0.2-0.9) had a reduced risk of breast cancer mortality, compared to ER intensity = 1 (p trend = 0.02). Neither ER protein expression nor intensity influenced Hispanic survival disparities. CONCLUSIONS Estrogen receptor percent positive staining is not independently related to breast cancer survival after adjustment for other survival-related factors. ER intensity, in contrast, demonstrates promise for prognostic utility.
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Affiliation(s)
- Deirdre A Hill
- Internal Medicine Department and Comprehensive Cancer Center, 1 University of New Mexico, MSC 10 5550, Albuquerque, NM, 87131-0001, USA.
| | - Marc Barry
- Department of Pathology, University of New Mexico, Albuquerque, NM, USA
| | - Charles Wiggins
- Internal Medicine Department and Comprehensive Cancer Center, 1 University of New Mexico, MSC 10 5550, Albuquerque, NM, 87131-0001, USA
| | - Andrea Nibbe
- Internal Medicine Department and Comprehensive Cancer Center, 1 University of New Mexico, MSC 10 5550, Albuquerque, NM, 87131-0001, USA
| | - Melanie Royce
- Internal Medicine Department and Comprehensive Cancer Center, 1 University of New Mexico, MSC 10 5550, Albuquerque, NM, 87131-0001, USA
| | - Eric Prossnitz
- Department of Molecular Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Lesley Lomo
- Department of Pathology, University of New Mexico, Albuquerque, NM, USA
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10
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Abstract
Histological grade is one of the most commonly used prognostic factors for patients diagnosed with breast cancer. However, conventional grading has proven technically challenging, and up to 60% of the tumors are classified as histological grade 2, which represents a heterogeneous cohort less informative for clinical decision making. In an attempt to study and extend the molecular puzzle of histologically graded breast cancer, we have in this pilot project searched for additional protein biomarkers in a new space of the proteome. To this end, we have for the first time performed protein expression profiling of breast cancer tumor tissue, using recombinant antibody microarrays, targeting mainly immunoregulatory proteins. Thus, we have explored the immune system as a disease-specific sensor (clinical immunoproteomics). Uniquely, the results showed that several biologically relevant proteins reflecting histological grade could be delineated. In more detail, the tentative biomarker panels could be used to i) build a candidate model classifying grade 1 vs. grade 3 tumors, ii) demonstrate the molecular heterogeneity among grade 2 tumors, and iii) potentially re-classify several of the grade 2 tumors to more like grade 1 or grade 3 tumors. This could, in the long-term run, lead to improved prognosis, by which the patients could benefit from improved tailored care.
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11
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Nordenskjöld A, Fohlin H, Fornander T, Löfdahl B, Skoog L, Stål O. Progesterone receptor positivity is a predictor of long-term benefit from adjuvant tamoxifen treatment of estrogen receptor positive breast cancer. Breast Cancer Res Treat 2016; 160:313-322. [PMID: 27722840 PMCID: PMC5065613 DOI: 10.1007/s10549-016-4007-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 09/21/2016] [Indexed: 12/11/2022]
Abstract
Purpose The independent predictive information from progesterone receptor (PgR) positivity for breast cancer treated with tamoxifen has been questioned after an overview by the Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). However, the studies in the overview were to a large content performed before modern PgR immunohistochemistry (IHC) was developed. We therefore investigated the predictive value of PgR determined with IHC in estrogen receptor (ER)-positive tumors from patients participating in the Stockholm trial of adjuvant tamoxifen therapy. Methods The Stockholm Breast Cancer Study Group conducted a randomized trial during 1976 through 1990 comparing adjuvant tamoxifen versus control. The patients were stratified according to tumor size and lymph node status in high-risk and low-risk groups. In this study, we evaluated 618 patients with ER-positive “low-risk” breast cancer (size ≤ 30 mm, lymph node-negative) for whom PgR was determined by IHC at one pathology laboratory. The median time of follow-up was 21 years. Results Patients with ER-positive tumors that were also PgR-positive by IHC did benefit from tamoxifen, while we could not show any long-term benefit for those with tumors positive for ER only (recurrence rate ratio 0.43, 95 % CI 0.29–0.62 and 0.87, 95 % CI 0.52–1.46, respectively). We further investigated the influence of different levels of PgR positivity on recurrence risk. The results show that at all receptor levels with ≥10 % stained PgR-positive cells, the patients did benefit from tamoxifen. There was no clear linear trend in benefit with increasing proportion of stained cells. Conclusions PgR positivity determined by IHC is a marker indicating long-term benefit from adjuvant tamoxifen in patients with ER-positive tumors. Electronic supplementary material The online version of this article (doi:10.1007/s10549-016-4007-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna Nordenskjöld
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden.,Department of Medicine, Southern Älvsborg Hospital, Borås, Sweden
| | - Helena Fohlin
- Department of Clinical and Experimental Medicine, Division of Oncology, Linköping University, Linköping, Sweden. .,Department of Clinical and Experimental Medicine, Regional Cancer Center Southeast Sweden, Linköping University, 581 85, Linköping, Sweden.
| | - Tommy Fornander
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden.,Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden.,Regional Cancer Center Stockholm-Gotland, Stockholm, Sweden
| | - Britta Löfdahl
- Department of Pathology, Unilabs, St Göran Hospital, Stockholm, Sweden
| | - Lambert Skoog
- Department of Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden
| | - Olle Stål
- Department of Clinical and Experimental Medicine, Division of Oncology, Linköping University, Linköping, Sweden
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Dai X, Xiang L, Li T, Bai Z. Cancer Hallmarks, Biomarkers and Breast Cancer Molecular Subtypes. J Cancer 2016; 7:1281-94. [PMID: 27390604 PMCID: PMC4934037 DOI: 10.7150/jca.13141] [Citation(s) in RCA: 247] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 05/19/2016] [Indexed: 12/13/2022] Open
Abstract
Breast cancer is a complex disease encompassing multiple tumor entities, each characterized by distinct morphology, behavior and clinical implications. Besides estrogen receptor, progesterone receptor and human epidermal growth factor receptor 2, novel biomarkers have shown their prognostic and predictive values, complicating our understanding towards to the heterogeneity of such cancers. Ten cancer hallmarks have been proposed by Weinberg to characterize cancer and its carcinogenesis. By reviewing biomarkers and breast cancer molecular subtypes, we propose that the divergent outcome observed from patients stratified by hormone status are driven by different cancer hallmarks. 'Sustaining proliferative signaling' further differentiates cancers with positive hormone receptors. 'Activating invasion and metastasis' and 'evading immune destruction' drive the differentiation of triple negative breast cancers. 'Resisting cell death', 'genome instability and mutation' and 'deregulating cellular energetics' refine breast cancer classification with their predictive values. 'Evading growth suppressors', 'enabling replicative immortality', 'inducing angiogenesis' and 'tumor-promoting inflammation' have not been involved in breast cancer classification which need more focus in the future biomarker-related research. This review novels in its global view on breast cancer heterogeneity, which clarifies many confusions in this field and contributes to precision medicine.
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Affiliation(s)
- Xiaofeng Dai
- National Engineering Laboratory for Cereal Fermentation Technology, School of Biotechnology, Jiangnan University, Wuxi, Jiangsu, P.R.China
| | - Liangjian Xiang
- National Engineering Laboratory for Cereal Fermentation Technology, School of Biotechnology, Jiangnan University, Wuxi, Jiangsu, P.R.China
| | - Ting Li
- National Engineering Laboratory for Cereal Fermentation Technology, School of Biotechnology, Jiangnan University, Wuxi, Jiangsu, P.R.China
| | - Zhonghu Bai
- National Engineering Laboratory for Cereal Fermentation Technology, School of Biotechnology, Jiangnan University, Wuxi, Jiangsu, P.R.China
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Ekholm M, Bendahl PO, Fernö M, Nordenskjöld B, Stål O, Rydén L. Two Years of Adjuvant Tamoxifen Provides a Survival Benefit Compared With No Systemic Treatment in Premenopausal Patients With Primary Breast Cancer: Long-Term Follow-Up (> 25 years) of the Phase III SBII:2pre Trial. J Clin Oncol 2016; 34:2232-8. [PMID: 27161974 DOI: 10.1200/jco.2015.65.6272] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE The aim of this study was to evaluate the long-term effect of 2 years of adjuvant tamoxifen compared with no systemic treatment (control) in premenopausal patients with breast cancer over different time periods through long-term (> 25 years) follow-up. PATIENTS AND METHODS Premenopausal patients with primary breast cancer (N = 564) were randomly assigned to 2 years of tamoxifen (n = 276) or no systemic treatment (n = 288). Data regarding date and cause of death were obtained from the Swedish Cause of Death Register. End points were cumulative mortality (CM) and cumulative breast cancer-related mortality (CBCM). The median follow-up for the 250 patients still alive in April 2014 was 26.3 years (range, 22.7 to 29.7 years). RESULTS In patients with estrogen receptor-positive tumors (n = 362), tamoxifen was associated with a marginal reduction in CM (hazard ratio [HR], 0.77; 95% CI, 0.58 to 1.03; P = .075) and a significant reduction in CBCM (HR, 0.73; 95% CI, 0.53 to 0.99; P = .046). The effect seemed to vary over time (CM years 0 to 5: HR, 1.05; 95% CI, 0.64 to 1.73; years > 5 to 15: HR, 0.58; 95% CI, 0.37 to 0.91; and after 15 years: HR, 0.82; 95% CI, 0.48 to 1.42; CBCM years 0 to 5: HR, 1.09; 95% CI, 0.65 to 1.82; years > 5 to 15: HR, 0.53; 95% CI, 0.33 to 0.86; and after 15 years: HR, 0.72; 95% CI, 0.36 to 1.44). CONCLUSION Two years of adjuvant tamoxifen resulted in a long-term survival benefit in premenopausal patients with estrogen receptor-positive primary breast cancer.
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Affiliation(s)
- Maria Ekholm
- Maria Ekholm, Pär-Ola Bendahl, Mårten Fernö, and Lisa Rydén, Lund University, Lund; Maria Ekholm, Ryhov County Hospital, Jönköping; and Bo Nordenskjöld and Olle Stål, Linköping University, Linköping, Sweden.
| | - Pär-Ola Bendahl
- Maria Ekholm, Pär-Ola Bendahl, Mårten Fernö, and Lisa Rydén, Lund University, Lund; Maria Ekholm, Ryhov County Hospital, Jönköping; and Bo Nordenskjöld and Olle Stål, Linköping University, Linköping, Sweden
| | - Mårten Fernö
- Maria Ekholm, Pär-Ola Bendahl, Mårten Fernö, and Lisa Rydén, Lund University, Lund; Maria Ekholm, Ryhov County Hospital, Jönköping; and Bo Nordenskjöld and Olle Stål, Linköping University, Linköping, Sweden
| | - Bo Nordenskjöld
- Maria Ekholm, Pär-Ola Bendahl, Mårten Fernö, and Lisa Rydén, Lund University, Lund; Maria Ekholm, Ryhov County Hospital, Jönköping; and Bo Nordenskjöld and Olle Stål, Linköping University, Linköping, Sweden
| | - Olle Stål
- Maria Ekholm, Pär-Ola Bendahl, Mårten Fernö, and Lisa Rydén, Lund University, Lund; Maria Ekholm, Ryhov County Hospital, Jönköping; and Bo Nordenskjöld and Olle Stål, Linköping University, Linköping, Sweden
| | - Lisa Rydén
- Maria Ekholm, Pär-Ola Bendahl, Mårten Fernö, and Lisa Rydén, Lund University, Lund; Maria Ekholm, Ryhov County Hospital, Jönköping; and Bo Nordenskjöld and Olle Stål, Linköping University, Linköping, Sweden
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Ji J, Sundquist J, Sundquist K. Association of tamoxifen with meningioma: a population-based study in Sweden. Eur J Cancer Prev 2016; 25:29-33. [PMID: 25642792 PMCID: PMC4885544 DOI: 10.1097/cej.0000000000000133] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 12/23/2014] [Indexed: 11/26/2022]
Abstract
Previous studies suggest that hormone therapy may play an important role in the development of meningioma. However, it is unclear whether medication with tamoxifen can prevent meningioma. Our study cohort included all women who were diagnosed with breast cancer between 1961 and 2010, and a total of 227 535 women were identified with breast cancer with a median age at diagnosis of 63 years. Women diagnosed with breast cancer after 1987 were defined as tamoxifen exposed; those diagnosed with breast cancer before or during 1987 were defined as not exposed to tamoxifen. Standardized incidence ratios (SIRs) were used to calculate the risk of subsequent meningioma. Of these women, 223 developed meningioma. For women without tamoxifen exposure, the risk of meningioma was significantly increased, with an SIR of 1.54 (95% confidence interval 1.30-1.81); the risk was not increased in those with tamoxifen exposure (SIR=1.06, 95% confidence interval 0.84-1.32). The increased risk of meningioma in women without tamoxifen exposure persisted during 10 years of follow-up. In this historical cohort study, we found that women diagnosed with breast cancer but not treated with tamoxifen had an increased incidence of meningioma, whereas the incidence was close to that of the general population in patients treated with tamoxifen. This suggests that tamoxifen may prevent the development of meningioma.
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Affiliation(s)
- Jianguang Ji
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Jan Sundquist
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California, USA
| | - Kristina Sundquist
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California, USA
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15
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Kos Z, Dabbs DJ. Biomarker assessment and molecular testing for prognostication in breast cancer. Histopathology 2015; 68:70-85. [DOI: 10.1111/his.12795] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Zuzana Kos
- University of Ottawa and The Ottawa Hospital; Ottawa ON Canada
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16
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Bostner J, Karlsson E, Eding CB, Perez-Tenorio G, Franzén H, Konstantinell A, Fornander T, Nordenskjöld B, Stål O. S6 kinase signaling: tamoxifen response and prognostic indication in two breast cancer cohorts. Endocr Relat Cancer 2015; 22:331-43. [PMID: 25972244 DOI: 10.1530/erc-14-0513] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Detection of signals in the mammalian target of rapamycin (mTOR) and the estrogen receptor (ER) pathways may be a future clinical tool for the prediction of adjuvant treatment response in primary breast cancer. Using immunohistological staining, we investigated the value of the mTOR targets p70-S6 kinase (S6K) 1 and 2 as biomarkers for tamoxifen benefit in two independent clinical trials comparing adjuvant tamoxifen with no tamoxifen or 5 years versus 2 years of tamoxifen treatment. In addition, the prognostic value of the S6Ks was evaluated. We found that S6K1 correlated with proliferation, HER2 status, and cytoplasmic AKT activity, whereas high protein expression levels of S6K2 and phosphorylated (p) S6K were more common in ER-positive, and low-proliferative tumors with pAKT-s473 localized to the nucelus. Nuclear accumulation of S6K1 was indicative of a reduced tamoxifen effect (hazard ratio (HR): 1.07, 95% CI: 0.53-2.81, P=0.84), compared with a significant benefit from tamoxifen treatment in patients without tumor S6K1 nuclear accumulation (HR: 0.42, 95% CI: 0.29-0.62, P<0.00001). Also S6K1 and S6K2 activation, indicated by pS6K-t389 expression, was associated with low benefit from tamoxifen (HR: 0.97, 95% CI: 0.50-1.87, P=0.92). In addition, high protein expression of S6K1, independent of localization, predicted worse prognosis in a multivariate analysis, P=0.00041 (cytoplasm), P=0.016 (nucleus). In conclusion, the mTOR-activated kinases S6K1 and S6K2 interfere with proliferation and response to tamoxifen. Monitoring their activity and intracellular localization may provide biomarkers for breast cancer treatment, allowing the identification of a group of patients less likely to benefit from tamoxifen and thus in need of an alternative or additional targeted treatment.
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Affiliation(s)
- Josefine Bostner
- Department of Clinical and Experimental MedicineDepartment of OncologyDepartment of Clinical and Experimental MedicineDivision of Dermatology, Linköping University, SE-58185 Linköping, SwedenDepartment of OncologyKarolinska University Hospital, Karolinska Institute, SE-17176 Stockholm, Sweden
| | - Elin Karlsson
- Department of Clinical and Experimental MedicineDepartment of OncologyDepartment of Clinical and Experimental MedicineDivision of Dermatology, Linköping University, SE-58185 Linköping, SwedenDepartment of OncologyKarolinska University Hospital, Karolinska Institute, SE-17176 Stockholm, Sweden
| | - Cecilia Bivik Eding
- Department of Clinical and Experimental MedicineDepartment of OncologyDepartment of Clinical and Experimental MedicineDivision of Dermatology, Linköping University, SE-58185 Linköping, SwedenDepartment of OncologyKarolinska University Hospital, Karolinska Institute, SE-17176 Stockholm, Sweden
| | - Gizeh Perez-Tenorio
- Department of Clinical and Experimental MedicineDepartment of OncologyDepartment of Clinical and Experimental MedicineDivision of Dermatology, Linköping University, SE-58185 Linköping, SwedenDepartment of OncologyKarolinska University Hospital, Karolinska Institute, SE-17176 Stockholm, Sweden
| | - Hanna Franzén
- Department of Clinical and Experimental MedicineDepartment of OncologyDepartment of Clinical and Experimental MedicineDivision of Dermatology, Linköping University, SE-58185 Linköping, SwedenDepartment of OncologyKarolinska University Hospital, Karolinska Institute, SE-17176 Stockholm, Sweden
| | - Aelita Konstantinell
- Department of Clinical and Experimental MedicineDepartment of OncologyDepartment of Clinical and Experimental MedicineDivision of Dermatology, Linköping University, SE-58185 Linköping, SwedenDepartment of OncologyKarolinska University Hospital, Karolinska Institute, SE-17176 Stockholm, Sweden
| | - Tommy Fornander
- Department of Clinical and Experimental MedicineDepartment of OncologyDepartment of Clinical and Experimental MedicineDivision of Dermatology, Linköping University, SE-58185 Linköping, SwedenDepartment of OncologyKarolinska University Hospital, Karolinska Institute, SE-17176 Stockholm, Sweden
| | - Bo Nordenskjöld
- Department of Clinical and Experimental MedicineDepartment of OncologyDepartment of Clinical and Experimental MedicineDivision of Dermatology, Linköping University, SE-58185 Linköping, SwedenDepartment of OncologyKarolinska University Hospital, Karolinska Institute, SE-17176 Stockholm, Sweden
| | - Olle Stål
- Department of Clinical and Experimental MedicineDepartment of OncologyDepartment of Clinical and Experimental MedicineDivision of Dermatology, Linköping University, SE-58185 Linköping, SwedenDepartment of OncologyKarolinska University Hospital, Karolinska Institute, SE-17176 Stockholm, Sweden
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Vuong D, Simpson PT, Green B, Cummings MC, Lakhani SR. Molecular classification of breast cancer. Virchows Arch 2014; 465:1-14. [PMID: 24878755 DOI: 10.1007/s00428-014-1593-7] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 05/11/2014] [Indexed: 01/01/2023]
Abstract
Breast cancer is a complex, multifaceted disease encompassing a great variety of entities that show considerable variation in clinical, morphological and molecular attributes. Traditional classifications including histological assessment and clinical staging are used to guide patient management. In recent years, there has been exponential progress in molecular analysis with profound implications for our understanding of breast cancer biology and, hence, classification. There are now genome-based frameworks for the molecular categorisation of breast cancer including the development of prognostic and predictive signatures that potentially allow individualisation of treatment. Here we review the current state of the molecular classifications of in situ and invasive breast cancer including special subtypes. Future perspectives are also provided.
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Affiliation(s)
- Darina Vuong
- The University of Queensland, UQ Centre for Clinical Research, Herston, Brisbane, QLD, 4029, Australia
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18
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Olsson N, Carlsson P, James P, Hansson K, Waldemarson S, Malmström P, Fernö M, Ryden L, Wingren C, Borrebaeck CAK. Grading breast cancer tissues using molecular portraits. Mol Cell Proteomics 2013; 12:3612-23. [PMID: 23982162 PMCID: PMC3861711 DOI: 10.1074/mcp.m113.030379] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Tumor progression and prognosis in breast cancer patients are difficult to assess using current clinical and laboratory parameters, where a pathological grading is indicative of tumor aggressiveness. This grading is based on assessments of nuclear grade, tubule formation, and mitotic rate. We report here the first protein signatures associated with histological grades of breast cancer, determined using a novel affinity proteomics approach. We profiled 52 breast cancer tissue samples by combining nine antibodies and label-free LC-MS/MS, which generated detailed quantified proteomic maps representing 1,388 proteins. The results showed that we could define in-depth molecular portraits of histologically graded breast cancer tumors. Consequently, a 49-plex candidate tissue protein signature was defined that discriminated between histological grades 1, 2, and 3 of breast cancer tumors with high accuracy. Highly biologically relevant proteins were identified, and the differentially expressed proteins indicated further support for the current hypothesis regarding remodeling of the tumor microenvironment during tumor progression. The protein signature was corroborated using meta-analysis of transcriptional profiling data from an independent patient cohort. In addition, the potential for using the markers to estimate the likelihood of long-term metastasis-free survival was also indicated. Taken together, these molecular portraits could pave the way for improved classification and prognostication of breast cancer.
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Affiliation(s)
- Niclas Olsson
- Department of Immunotechnology and CREATE HEALTH, Lund University, Medicon Village, SE-223 81 Lund, Sweden
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19
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Klintman M, Nilsson F, Bendahl PO, Fernö M, Liljegren G, Emdin S, Malmström P. A prospective, multicenter validation study of a prognostic index composed of S-phase fraction, progesterone receptor status, and tumour size predicts survival in node-negative breast cancer patients: NNBC, the node-negative breast cancer trial. Ann Oncol 2013; 24:2284-91. [PMID: 23704202 DOI: 10.1093/annonc/mdt186] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In a retrospective study on node-negative breast cancer, a prognostic index consisting of a proliferation factor, S-phase fraction (SPF), progesterone receptor status (PR), and tumour size identified one-third of patients as high risk, with a sixfold increased risk of breast cancer death. This prospective multicenter cohort study was set up to validate the index. PATIENTS AND METHODS In 576 T1-2N0 patients <60 years, prospective analyses of PR and SPF were carried out. High risk was defined as ≥2 of the following: size >20 mm, PR-negativity, and high SPF (in the absence of SPF, Bloom-Richardson grade 3). Median follow-up was 17.8 years. RESULTS Thirty-one percent were high risk. In univariate analysis, the index was prognostic for breast cancer-specific survival after 5 years [hazard ratio (HR) = 4.7, 95% confidence interval (95% CI) 2.5-8.9], 10 years (HR = 2.2, 95% CI 1.5-3.3), and 15 years (HR = 1.7, 95% CI 1.2-2.5), and remained significant after adjustment for adjuvant medical treatment and age. In the 37% of patients with no risk factors, only one patient died of breast cancer the first 5 years. CONCLUSIONS This prospective study validates a prognostic index consisting of a proliferation factor, PR-status, and tumour size. The index may be helpful for prognostic considerations and for selection of patients in need of adjuvant therapy.
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Affiliation(s)
- M Klintman
- Department of Clinical Sciences, Division of Oncology, Lund University, Lund, Sweden.
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20
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Holm K, Grabau D, Lövgren K, Aradottir S, Gruvberger-Saal S, Howlin J, Saal LH, Ethier SP, Bendahl PO, Stål O, Malmström P, Fernö M, Rydén L, Hegardt C, Borg Å, Ringnér M. Global H3K27 trimethylation and EZH2 abundance in breast tumor subtypes. Mol Oncol 2012; 6:494-506. [PMID: 22766277 DOI: 10.1016/j.molonc.2012.06.002] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 05/11/2012] [Accepted: 06/12/2012] [Indexed: 01/03/2023] Open
Abstract
Polycomb repressive complex 2 (PRC2) and its core member enhancer of zeste homolog 2 (EZH2) mediate the epigenetic gene silencing mark: trimethylation of lysine 27 on histone 3 (H3K27me3). H3K27me3 is characteristic of the chromatin at genes involved in developmental regulation in undifferentiated cells. Overexpression of EZH2 has been found in several cancer types such as breast, prostate, melanoma and bladder cancer. Moreover, overexpression is associated with highly proliferative and aggressive types of breast and prostate tumors. We have analyzed the abundance of EZH2 and H3K27me3 using immunohistochemistry in two large and well-characterized breast tumor data sets encompassing more than 400 tumors. The results have been analyzed in relation to the molecular subtypes of breast tumors (basal-like, luminal A, luminal B, HER2-enriched and normal-like), as well as in subtypes defined by clinical markers (triple negative, ER+/HER2-/Ki67low, ER+/HER2-/Ki67high and HER2+), and were validated in representative breast cancer cell lines by western blot. We found significantly different expression of both EZH2 and H3K27me3 across all subtypes with high abundance of EZH2 in basal-like, triple negative and HER2-enriched tumors, and high H3K27me3 in luminal A, HER2-enriched and normal-like tumors. Intriguingly, the two markers show an inverse correlation, particularly for the basal-like and triple negative tumors. Consequently, high expression of EZH2 was associated with poor distant disease-free survival whereas high expression of H3K27me3 was associated with better survival. Additionally, none of 182 breast tumors was found to carry a previously described EZH2 mutation affecting Tyr641. Our observation that increased expression of EZH2 does not necessarily correlate with increased abundance of H3K27me3 supports the idea that EZH2 can have effects beyond epigenetic silencing of target genes in breast cancer.
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Affiliation(s)
- Karolina Holm
- Department of Oncology, Clinical Sciences, Lund University, Skåne University Hospital, SE-221 85 Lund, Sweden.
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Le Romancer M, Poulard C, Cohen P, Sentis S, Renoir JM, Corbo L. Cracking the estrogen receptor's posttranslational code in breast tumors. Endocr Rev 2011; 32:597-622. [PMID: 21680538 DOI: 10.1210/er.2010-0016] [Citation(s) in RCA: 211] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Estrogen signaling pathways, because of their central role in regulating the growth and survival of breast tumor cells, have been identified as suitable and efficient targets for cancer therapies. Agents blocking estrogen activity are already widely used clinically, and many new molecules have entered clinical trials, but intrinsic or acquired resistance to treatment limits their efficacy. The basic molecular studies underlying estrogen signaling have defined the critical role of estrogen receptors (ER) in many aspects of breast tumorigenesis. However, important knowledge gaps remain about the role of posttranslational modifications (PTM) of ER in initiation and progression of breast carcinogenesis. Whereas major attention has been focused on the phosphorylation of ER, many other PTM (such as acetylation, ubiquitination, sumoylation, methylation, and palmitoylation) have been identified as events modifying ER expression and stability, subcellular localization, and sensitivity to hormonal response. This article will provide an overview of the current and emerging knowledge on ER PTM, with a particular focus on their deregulation in breast cancer. We also discuss their clinical relevance and the functional relationship between PTM. A thorough understanding of the complete picture of these modifications in ER carcinogenesis might not only open new avenues for identifying new markers for prognosis or prediction of response to endocrine therapy but also could promote the development of novel therapeutic strategies.
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Affiliation(s)
- Muriel Le Romancer
- Université de Lyon, Centre de Recherche en Cancérologie de Lyon, Centre Léon Bérard, Bâtiment Cheney D, 28 rue Laennec, 69373 Lyon Cedex 08, France.
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22
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Olsson E, Honeth G, Bendahl PO, Saal LH, Gruvberger-Saal S, Ringnér M, Vallon-Christersson J, Jönsson G, Holm K, Lövgren K, Fernö M, Grabau D, Borg A, Hegardt C. CD44 isoforms are heterogeneously expressed in breast cancer and correlate with tumor subtypes and cancer stem cell markers. BMC Cancer 2011; 11:418. [PMID: 21957977 PMCID: PMC3196967 DOI: 10.1186/1471-2407-11-418] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 09/29/2011] [Indexed: 01/16/2023] Open
Abstract
Background The CD44 cell adhesion molecule is aberrantly expressed in many breast tumors and has been implicated in the metastatic process as well as in the putative cancer stem cell (CSC) compartment. We aimed to investigate potential associations between alternatively spliced isoforms of CD44 and CSCs as well as to various breast cancer biomarkers and molecular subtypes. Methods We used q-RT-PCR and exon-exon spanning assays to analyze the expression of four alternatively spliced CD44 isoforms as well as the total expression of CD44 in 187 breast tumors and 13 cell lines. ALDH1 protein expression was determined by IHC on TMA. Results Breast cancer cell lines showed a heterogeneous expression pattern of the CD44 isoforms, which shifted considerably when cells were grown as mammospheres. Tumors characterized as positive for the CD44+/CD24- phenotype by immunohistochemistry were associated to all isoforms except the CD44 standard (CD44S) isoform, which lacks all variant exons. Conversely, tumors with strong expression of the CSC marker ALDH1 had elevated expression of CD44S. A high expression of the CD44v2-v10 isoform, which retain all variant exons, was correlated to positive steroid receptor status, low proliferation and luminal A subtype. The CD44v3-v10 isoform showed similar correlations, while high expression of CD44v8-v10 was correlated to positive EGFR, negative/low HER2 status and basal-like subtype. High expression of CD44S was associated with strong HER2 staining and also a subgroup of basal-like tumors. Unsupervised hierarchical cluster analysis of CD44 isoform expression data divided tumors into four main clusters, which showed significant correlations to molecular subtypes and differences in 10-year overall survival. Conclusions We demonstrate that individual CD44 isoforms can be associated to different breast cancer subtypes and clinical markers such as HER2, ER and PgR, which suggests involvement of CD44 splice variants in specific oncogenic signaling pathways. Efforts to link CD44 to CSCs and tumor progression should consider the expression of various CD44 isoforms.
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Affiliation(s)
- Eleonor Olsson
- Department of Oncology, Clinical Sciences, Lund University, Lund, Sweden.
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Fuchs-Young R, Shirley SH, Lambertz I, Colby JKL, Tian J, Johnston D, Gimenez-Conti IB, Donehower LA, Conti CJ, Hursting SD. P53 genotype as a determinant of ER expression and tamoxifen response in the MMTV-Wnt-1 model of mammary carcinogenesis. Breast Cancer Res Treat 2010; 130:399-408. [PMID: 21191649 DOI: 10.1007/s10549-010-1308-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2009] [Accepted: 12/10/2010] [Indexed: 10/18/2022]
Abstract
Clinical studies show that estrogen receptor-α (ER) expressing tumors tend to have better prognosis, respond to antiestrogen therapy and have wild-type p53. Conversely, tumors with inactivating mutations in p53 tend to have worse outcomes and to be ER-negative and unresponsive to antihormone treatment. Previous studies from our laboratory have shown that p53 regulates ER expression transcriptionally, by binding the ER promoter and forming a complex with CARM1, CBP, c-Jun, RNA polymerase II and Sp1. In this study, the MMTV-Wnt-1 transgenic mouse model was used to demonstrate that p53 regulation of ER expression and function is not solely an in vitro phenomenon, but it is also operational in mammary tumorigenesis in vivo. The expression of ER and the ability to respond to tamoxifen were determined in mammary tumors arising in p53 wild type (WT) or p53 heterozygous (HT) animals carrying the Wnt-1 transgene. In p53 WT mice, development of ER-positive tumors was delayed by tamoxifen treatment, while tumors arising in p53 HT mice had significantly reduced levels of ER and were not affected by tamoxifen. P53 null tumors were also found in the p53 HT mice and these tumors were ER-negative. ER expression was upregulated in mouse mammary tumor cell lines following transfection with WT p53 or treatment with doxorubicin. These data demonstrate that p53 regulates ER expression in vivo, and affects response to tamoxifen. Results also provide an explanation for the concordant relationship between these prognostic proteins in human breast tumors.
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Affiliation(s)
- Robin Fuchs-Young
- Department of Molecular Carcinogenesis, The Virginia Harris Cockrell Cancer Research Center at The University of Texas MD Anderson Cancer Center, Science Park Research Division, 1808 Park Road 1C, Smithville, TX 78957, USA.
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Rennstam K, McMichael N, Berglund P, Honeth G, Hegardt C, Rydén L, Luts L, Bendahl PO, Hedenfalk I. Numb protein expression correlates with a basal-like phenotype and cancer stem cell markers in primary breast cancer. Breast Cancer Res Treat 2010; 122:315-24. [PMID: 19795205 DOI: 10.1007/s10549-009-0568-x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2009] [Accepted: 09/19/2009] [Indexed: 11/27/2022]
Abstract
Decreased expression of Numb, resulting in activation of the proto-oncogene Notch1 and reduction in the tumor suppressor p53, has been demonstrated in mammary carcinomas. The aim of this study was to investigate the relationship between Numb protein expression and clinicopathological characteristics, tumor biological subtypes and putative cancer stem cell markers in a well-characterized cohort of primary human breast cancers. Immunohistochemistry was performed on tissue microarrays of primary invasive breast tumors using a polyclonal anti-Numb primary antibody. Of the 241 tumors evaluated, 50 (21%) displayed deficient or reduced Numb immunoreactivity. Retained Numb expression was significantly correlated to estrogen (ER) and progesterone receptor (PR) positivity (P < 0.001 and P = 0.004, respectively). Interestingly, we found that a higher percentage of the tumors with deficient or reduced Numb expression belonged to the triple-negative (ER-/PR-/HER2-) subgroup compared to tumors with retained Numb expression (P = 0.004). Transcriptional profiling of a subset of these tumors linked NOTCH1 and BIRC5, both downstream targets of Numb, to the triple-negative subgroup in an inverse manner. Typically, subgroups characterized by the low expression of Numb expressed higher levels of NOTCH1 and BIRC5 (encoding survivin). We also found deficient expression of Numb in a significantly higher proportion of BRCA1 dependent tumors, which are usually triple-negative, compared to sporadic tumors. The expression of Numb in 14 breast cancer cell lines correlated similarly to their respective molecular subtypes. We further established an inverse correlation between the Numb expression levels and the CD44+/CD24- cancer stem cell phenotype (P = 0.05) in primary tumors. Finally, decreased Numb expression was associated with poorer distant disease-free survival (P = 0.01). Taken together, our results indicate that loss of Numb expression is a marker of tumor aggressiveness, potentially linked to BRCA1 status and a cancer stem cell phenotype in primary breast cancer.
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Affiliation(s)
- Karin Rennstam
- Department of Oncology, Clinical Sciences, Lund University, Barngatan 2B, 221 85, Lund, Sweden
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25
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Combinatorial biomarker expression in breast cancer. Breast Cancer Res Treat 2010; 120:293-308. [PMID: 20107892 DOI: 10.1007/s10549-010-0746-x] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 01/12/2010] [Indexed: 02/06/2023]
Abstract
Current clinical management of breast cancer relies on the availability of robust clinicopathological variables and few well-defined biological markers. Recent microarray-based expression profiling studies have emphasised the importance of the molecular portraits of breast cancer and the possibility of classifying breast cancer into biologically and molecularly distinct groups. Subsequent large scale immunohistochemical studies have demonstrated that the added value of studying the molecular biomarker expression in combination rather than individually. Oestrogen (ER) and progesterone (PR) receptors and HER2 are currently used in routine pathological assessment of breast cancer. Additional biomarkers such as proliferation markers and 'basal' markers are likely to be included in the future. A better understanding of the prognostic and predictive value of combinatorial assessment of biomarker expression could lead to improved breast cancer management in routine clinical practice and would add to our knowledge concerning the variation in behaviour and response to therapy. Here, we review the evidence on the value of assessing biomarker expression in breast cancer individually and in combination and its relation to the recent molecular classification of breast cancer.
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Johansson P, Fohlin H, Arnesson LG, Dufmats M, Nordenskjöld K, Nordenskjöld B, Stål O, The South-East Sweden Breast Cancer, Agrup M, Arnesson LG, Asking B, Blomkvist T, Bång H, Dabrosin C, Dufmats M, Einarsson E, Fohlin H, Gustavsson R, Klintenberg C, Linderholm B, Malmström A, Malterling R, Sundquist M, Norberg B, Rundcrantz A, Skoog P, Starkhammar H, Askmalm MS, Tejler G, Thorstenson S, Vahlin S, Vitak B. Improved survival for women with stage I breast cancer in south-east Sweden: a comparison between two time periods before and after increased use of adjuvant systemic therapy. Acta Oncol 2009; 48:504-13. [PMID: 19235568 DOI: 10.1080/02841860902718754] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE Continuous minor steps of improvement in the management of breast cancer have resulted in decreased mortality rates during the last decades. The aim of this study was to compare the clinical outcome of patients with stage I breast cancer diagnosed during two time periods that differed with respect to adjuvant systemic therapy. MATERIAL AND METHODS The studied population consisted of all women < 60 years of age, who were diagnosed breast cancer stage I between 1986 and 1999 in south-east Sweden, a total of 1 407 cases. The cohort was divided into two groups based on the management programmes of 1986 and 1992, hereafter referred to as Period 1 and Period 2. Before 1992 the only adjuvant systemic therapy recommended was tamoxifen for hormone receptor positive patients aged 50 years or older. During Period 2 the use of adjuvant treatment was extended to younger patients at high risk, identified by a high tumour S-phase fraction, with either hormonal or cytotoxic treatment. RESULTS The estimated distant recurrence-free survival rate was significantly higher during Period 2 than during Period 1 (p = 0.008). Subgroup analysis showed that the most evident reduction of distant recurrence risk was among hormone receptor-negative patients (HR = 0.58, 95% CI 0.31-1.09, p = 0.09) and among patients with a high tumour S-phase fraction (HR = 0.53, 0.30-0.93, p = 0.028). The risk reduction between the periods was still statistically significant in multivariate analysis when adjusting for different tumour characteristics and treatment modalities, indicating an influence of other factors not controlled for. One such factor may be the duration of tamoxifen treatment, which likely was more frequently five years during Period 2 than during Period 1. CONCLUSIONS We conclude that the causes of the increase in distant recurrence free survival for women with breast cancer stage I are complex. The results support though that high-risk subgroups of stage I breast cancer patients did benefit from increased use of systemic therapy as a consequence of an updated management programme.
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Vendrell JA, Robertson KE, Ravel P, Bray SE, Bajard A, Purdie CA, Nguyen C, Hadad SM, Bieche I, Chabaud S, Bachelot T, Thompson AM, Cohen PA. A candidate molecular signature associated with tamoxifen failure in primary breast cancer. Breast Cancer Res 2008; 10:R88. [PMID: 18928543 PMCID: PMC2614524 DOI: 10.1186/bcr2158] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Revised: 10/13/2008] [Accepted: 10/17/2008] [Indexed: 01/25/2023] Open
Abstract
Introduction Few markers are available that can predict response to tamoxifen treatment in estrogen receptor (ER)-positive breast cancers. Identification of such markers would be clinically useful. We attempted to identify molecular markers associated with tamoxifen failure in breast cancer. Methods Eighteen initially ER-positive patients treated with tamoxifen requiring salvage surgery (tamoxifen failure [TF] patients) were compared with 17 patients who were disease free 5 years after surgery plus tamoxifen adjuvant therapy (control patients). cDNA microarray, real-time quantitative PCR, and immunohistochemistry on tissue microarrays were used to generate and confirm a gene signature associated with tamoxifen failure. An independent series of 33 breast tumor samples from patients who relapsed (n = 14) or did not relapse (n = 19) under tamoxifen treatment from a different geographic location was subsequently used to explore the gene expression signature identified. Results Using a screening set of 18 tumor samples (from eight control patients and 10 TF patients), a 47-gene signature discriminating between TF and control samples was identified using cDNA arrays. In addition to ESR1/ERα, the top-ranked genes selected by statistical cross-analyses were MET, FOS, SNCG, IGFBP4, and BCL2, which were subsequently validated in a larger set of tumor samples (from 17 control patients and 18 TF patients). Confirmation at the protein level by tissue microarray immunohistochemistry was observed for ER-α, γ-synuclein, and insulin-like growth factor binding protein 4 proteins in the 35 original samples. In an independent series of breast tumor samples (19 nonrelapsing and 14 relapsing), reduced expression of ESR1/ERα, IGFBP4, SNCG, BCL2, and FOS was observed in the relapsing group and was associated with a shorter overall survival. Low mRNA expression levels of ESR1/ERα, BCL2, and FOS were also associated with a shorter relapse-free survival (RFS). Using a Cox multivariate regression analysis, we identified BCL2 and FOS as independent prognostic markers associated with RFS. Finally, the BCL2/FOS signature was demonstrated to have more accurate prognostic value for RFS than ESR1/ERα alone (likelihood ratio test). Conclusions We identified molecular markers including a BCL2/FOS signature associated with tamoxifen failure; these markers may have clinical potential in the management of ER-positive breast cancer.
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Zilli M, Grassadonia A, Tinari N, Di Giacobbe A, Gildetti S, Giampietro J, Natoli C, Iacobelli S. Molecular mechanisms of endocrine resistance and their implication in the therapy of breast cancer. Biochim Biophys Acta Rev Cancer 2008; 1795:62-81. [PMID: 18804516 DOI: 10.1016/j.bbcan.2008.08.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2008] [Revised: 08/11/2008] [Accepted: 08/14/2008] [Indexed: 01/04/2023]
Abstract
The use of endocrine agents is a safe and effective treatment in the management of hormone-sensitive breast cancer. Unfortunately, sooner or later, tumor cells develop resistance to endocrine manipulation making useless this approach. During the last decade, new molecules and intracellular signaling pathways involved in endocrine resistance have been identified. Several studies have documented that estrogen receptor signaling may maintain a pivotal role in the tumor growth despite the failure of a previous hormonal treatment. In this review we will discuss the general principles for optimizing the choice of endocrine therapy based on an understanding of the molecular mechanisms responsible for resistance to the different anti-hormonal agents.
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Affiliation(s)
- Marinella Zilli
- Department of Oncology and Neurosciences, University G D'Annunzio Medical School, Via dei Vestini, Chieti, Italy
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Brommesson S, Jönsson G, Strand C, Grabau D, Malmström P, Ringnér M, Fernö M, Hedenfalk I. Tiling array-CGH for the assessment of genomic similarities among synchronous unilateral and bilateral invasive breast cancer tumor pairs. BMC Clin Pathol 2008; 8:6. [PMID: 18616792 PMCID: PMC2474633 DOI: 10.1186/1472-6890-8-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Accepted: 07/10/2008] [Indexed: 02/07/2023] Open
Abstract
Background Today, no objective criteria exist to differentiate between individual primary tumors and intra- or intermammary dissemination respectively, in patients diagnosed with two or more synchronous breast cancers. To elucidate whether these tumors most likely arise through clonal expansion, or whether they represent individual primary tumors is of tumor biological interest and may have clinical implications. In this respect, high resolution genomic profiling may provide a more reliable approach than conventional histopathological and tumor biological factors. Methods 32 K tiling microarray-based comparative genomic hybridization (aCGH) was used to explore the genomic similarities among synchronous unilateral and bilateral invasive breast cancer tumor pairs, and was compared with histopathological and tumor biological parameters. Results Based on global copy number profiles and unsupervised hierarchical clustering, five of ten (p = 1.9 × 10-5) unilateral tumor pairs displayed similar genomic profiles within the pair, while only one of eight bilateral tumor pairs (p = 0.29) displayed pair-wise genomic similarities. DNA index, histological type and presence of vessel invasion correlated with the genomic analyses. Conclusion Synchronous unilateral tumor pairs are often genomically similar, while synchronous bilateral tumors most often represent individual primary tumors. However, two independent unilateral primary tumors can develop synchronously and contralateral tumor spread can occur. The presence of an intraductal component is not informative when establishing the independence of two tumors, while vessel invasion, the presence of which was found in clustering tumor pairs but not in tumor pairs that did not cluster together, supports the clustering outcome. Our data suggest that genomically similar unilateral tumor pairs may represent a more aggressive disease that requires the addition of more severe treatment modalities, and underscores the importance of evaluating the clonality of multiple tumors for optimal patient management. In summary, our findings demonstrate the importance of evaluating the properties of both tumors in order to determine the most optimal patient management.
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Affiliation(s)
- Sara Brommesson
- Division of Oncology, Department of Clinical Sciences, Lund University, SE-221 85 Lund, Sweden.
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Honeth G, Bendahl PO, Ringnér M, Saal LH, Gruvberger-Saal SK, Lövgren K, Grabau D, Fernö M, Borg A, Hegardt C. The CD44+/CD24- phenotype is enriched in basal-like breast tumors. Breast Cancer Res 2008; 10:R53. [PMID: 18559090 PMCID: PMC2481503 DOI: 10.1186/bcr2108] [Citation(s) in RCA: 413] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Revised: 06/12/2008] [Accepted: 06/17/2008] [Indexed: 12/18/2022] Open
Abstract
Introduction Human breast tumors are heterogeneous and consist of phenotypically diverse cells. Breast cancer cells with a CD44+/CD24- phenotype have been suggested to have tumor-initiating properties with stem cell-like and invasive features, although it is unclear whether their presence within a tumor has clinical implications. There is also a large heterogeneity between tumors, illustrated by reproducible stratification into various subtypes based on gene expression profiles or histopathological features. We have explored the prevalence of cells with different CD44/CD24 phenotypes within breast cancer subtypes. Methods Double-staining immunohistochemistry was used to quantify CD44 and CD24 expression in 240 human breast tumors for which information on other tumor markers and clinical characteristics was available. Gene expression data were also accessible for a cohort of the material. Results A considerable heterogeneity in CD44 and CD24 expression was seen both between and within tumors. A complete lack of both proteins was evident in 35% of the tumors, while 13% contained cells of more than one of the CD44+/CD24-, CD44-/CD24+ and CD44+/CD24+ phenotypes. CD44+/CD24- cells were detected in 31% of the tumors, ranging in proportion from only a few to close to 100% of tumor cells. The CD44+/CD24- phenotype was most common in the basal-like subgroup – characterized as negative for the estrogen and progesterone receptors as well as for HER2, and as positive for cytokeratin 5/14 and/or epidermal growth factor receptor, and particularly common in BRCA1 hereditary tumors, of which 94% contained CD44+/CD24- cells. The CD44+/CD24- phenotype was surprisingly scarce in HER2+ tumors, which had a predominantly CD24+ status. A CD44+/CD24- gene expression signature was generated, which included CD44 and α6-integrin (CD49f) among the top-ranked overexpressed genes. Conclusion We demonstrate an association between basal-like and particularly BRCA1 hereditary breast cancer and the presence of CD44+/CD24- cells. Not all basal-like tumors and very few HER2+ tumors, however, contain CD44+/CD24- cells, emphasizing that a putative tumorigenic ability may not be confined to cells of this phenotype and that other breast cancer stem cell markers remain to be identified.
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Affiliation(s)
- Gabriella Honeth
- Department of Oncology, Clinical Sciences, Lund University, Barngatan 2B, SE-221 85 Lund, Sweden.
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Affiliation(s)
- Emad A. Rakha
- Molecular Medical Sciences, University of Nottingham, Department of Histopathology, Nottingham City Hospital NHS Trust, Nottingham, United Kingdom
| | - Ian O. Ellis
- Molecular Medical Sciences, University of Nottingham, Department of Histopathology, Nottingham City Hospital NHS Trust, Nottingham, United Kingdom
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Fjøsne HE, Jacobsen AB, Lundgren S. Adjuvant cyclic Tamoxifen and Megestrol acetate treatment in postmenopausal breast cancer patients – Longterm follow-up. Eur J Surg Oncol 2008; 34:6-12. [PMID: 17881183 DOI: 10.1016/j.ejso.2007.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Accepted: 07/02/2007] [Indexed: 10/22/2022] Open
Abstract
AIMS To evaluate possible differences in effect on recurrence-free survival (RFS) and overall survival (OS) in node positive postmenopausal breast cancer patients receiving Tamoxifen or cyclic Tam and Megestrol acetate as adjuvant treatment. METHODS Between 1989 and 1994, 489 patients with pT(1-2)pN+ hormone receptor positive or unknown tumours were included in a randomized national multicenter study to receive either Tam alone or cyclic Tam (8 weeks) and MA (8 weeks) for 2 years. Final follow-up was completed as of June 2002. Time from start of treatment to first recurrence and novel primary breast tumour, overall survival and cancer specific survival were estimated. RESULTS No differences in RFS, OS or cancer specific survival were observed between the two treatment groups. CONCLUSIONS Adjuvant treatment used as standard Tam alone, compared to Tam and MA, as employed in this group of patients gave similar outcomes. Side effects that led to cessation of study medication were observed in both arms.
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Affiliation(s)
- H E Fjøsne
- Breast and Endocrine Unit, Department of Surgery, St. Olavs University Hospital, N-7006 Trondheim, Norway.
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Stendahl M, Rydén L, Nordenskjöld B, Jönsson PE, Landberg G, Jirström K. High progesterone receptor expression correlates to the effect of adjuvant tamoxifen in premenopausal breast cancer patients. Clin Cancer Res 2007; 12:4614-8. [PMID: 16899609 DOI: 10.1158/1078-0432.ccr-06-0248] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Tamoxifen has long been the drug of choice in adjuvant endocrine therapy of steroid hormone receptor-positive breast cancer, and it still remains important due to its well-documented beneficial effect. Hormone receptor status is often reported as "positive" or "negative" using 10% positive nuclei as a cutoff. In this study, we aimed to assess whether a further subclassification of hormone receptor status could enhance the treatment predictive value. EXPERIMENTAL DESIGN The immunohistochemical expression of estrogen receptor (ER) and progesterone receptor (PR) was quantified in tissue microarrays with tumors from 500 premenopausal breast cancer patients previously included in a randomized trial of adjuvant tamoxifen compared with an untreated control group. RESULTS Our findings show a gradually increasing tamoxifen effect in tumors with >10% ER-positive nuclei. However, when analyzing tamoxifen response according to various PR fractions, we found that it was primarily patients with tumors showing >75% PR-positive nuclei that responded to tamoxifen treatment, with an improved recurrence-free [relative risk, 0.42 (0.25-0.70); P = 0.001] as well as overall [relative risk, 0.49 (0.28-0.84); P = 0.010] survival. CONCLUSIONS Adjuvant tamoxifen improved recurrence-free and overall survival for premenopausal patients with tumors showing >75% PR-positive nuclei. No effect could be shown in tumors with fewer PR-positive nuclei. The PR was a stronger predictor of treatment response than the ER. Based on these findings, we suggest the implementation of a fractioned rather than dichotomized immunohistochemical evaluation of hormone receptors in clinical practice, possibly with greater emphasis on the PR than the ER.
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Affiliation(s)
- Maria Stendahl
- Department of Laboratory Medicine, Division of Pathology, Malmö University Hospital, Lund University, Malmö, Sweden
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Rakha EA, El-Sayed ME, Green AR, Paish EC, Powe DG, Gee J, Nicholson RI, Lee AHS, Robertson JFR, Ellis IO. Biologic and clinical characteristics of breast cancer with single hormone receptor positive phenotype. J Clin Oncol 2007; 25:4772-8. [PMID: 17876012 DOI: 10.1200/jco.2007.12.2747] [Citation(s) in RCA: 219] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE Response to endocrine therapy in breast cancer correlates with estrogen receptor (ER) and progesterone receptor (PgR) status. It is usually easier to decide treatment strategies in cases of double-positive/-negative phenotypes than in single-positive tumors. PATIENTS AND METHODS We have examined a large and well-characterized series of primary invasive breast carcinoma (1,944 cases) with long-term clinical follow-up and hormone therapy data. Patients were stratified according to ER and PgR expression and the study was focused on the single-positive groups (ER-/PgR+ and ER+/PgR-), to assess their main features and evaluate any prognostic and predictive difference between them and compare them with the double-positive/-negative tumors. RESULTS ER+/PgR-tumors were found more frequently in elderly, postmenopausal women. The majority were grade 2 ductal/no specific type carcinomas. There was no difference between the two groups with regard to lymph node stage. Survival analyses showed no difference between the two groups in terms of disease-free interval and overall survival. However, when compared with the double-negative phenotype, ER+/PgR-showed an association with better outcome but no such survival advantage was detected in case of ER-/PgR+ tumors. In the group of patients with ER+ tumors who received adjuvant hormonal therapy, absence of PgR (ER+/PgR-) was an independent predictor of development of recurrence and shorter survival and, hence, poorer response to hormonal therapy. CONCLUSION ER+/PgR-and ER-/PgR+ tumors are biologically and clinically distinct groups of breast cancer that may require different treatment strategies with ER-/PgR+ exhibiting more aggressive behavioral characteristics.
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Affiliation(s)
- Emad A Rakha
- Department of Histopathology and Surgery, School of Molecular Medical Sciences, Nottingham University Hospitals National Health Service Trust and University of Nottingham, Nottingham, United Kingdom.
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Kölble K. Morphological detection of hormone and growth factor receptors in breast cancer. RECENT RESULTS IN CANCER RESEARCH. FORTSCHRITTE DER KREBSFORSCHUNG. PROGRES DANS LES RECHERCHES SUR LE CANCER 2007; 176:201-9. [PMID: 17607927 DOI: 10.1007/978-3-540-46091-6_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
In the multidisciplinary effort of today's clinical oncology, histopathology has to deal increasingly with the genetic and proteomic profiles of neoplastic cells obtained in ever smaller samples via various diagnostic routes. None of the numerous molecular markers available has surpassed hormone and growth factor receptors in their relevance for the selection of targeted therapies. In the following, morphologic concepts and histopathologic methods pertinent to the clinically most important receptors are discussed with a focus on tumors of the breast.
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Affiliation(s)
- Konrad Kölble
- Centrum 5 für Diagnostiche und Präventive Labormedizin, Institut für Pathologie, Berlin, Germany
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Gruvberger-Saal SK, Bendahl PO, Saal LH, Laakso M, Hegardt C, Edén P, Peterson C, Malmström P, Isola J, Borg A, Fernö M. Estrogen receptor beta expression is associated with tamoxifen response in ERalpha-negative breast carcinoma. Clin Cancer Res 2007; 13:1987-94. [PMID: 17404078 DOI: 10.1158/1078-0432.ccr-06-1823] [Citation(s) in RCA: 138] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Endocrine therapies, such as tamoxifen, are commonly given to most patients with estrogen receptor (ERalpha)-positive breast carcinoma but are not indicated for persons with ERalpha-negative cancer. The factors responsible for response to tamoxifen in 5% to 10% of patients with ERalpha-negative tumors are not clear. The aim of the present study was to elucidate the biology and prognostic role of the second ER, ERbeta, in patients treated with adjuvant tamoxifen. EXPERIMENTAL DESIGN We investigated ERbeta by immunohistochemistry in 353 stage II primary breast tumors from patients treated with 2 years adjuvant tamoxifen, and generated gene expression profiles for a representative subset of 88 tumors. RESULTS ERbeta was associated with increased survival (distant disease-free survival, P = 0.01; overall survival, P = 0.22), and in particular within ERalpha-negative patients (P = 0.003; P = 0.04), but not in the ERalpha-positive subgroup (P = 0.49; P = 0.88). Lack of ERbeta conferred early relapse (hazard ratio, 14; 95% confidence interval, 1.8-106; P = 0.01) within the ERalpha-negative subgroup even after adjustment for other markers. ERalpha was an independent marker only within the ERbeta-negative tumors (hazard ratio, 0.44; 95% confidence interval, 0.21-0.89; P = 0.02). An ERbeta gene expression profile was identified and was markedly different from the ERalpha signature. CONCLUSION Expression of ERbeta is an independent marker for favorable prognosis after adjuvant tamoxifen treatment in ERalpha-negative breast cancer patients and involves a gene expression program distinct from ERalpha. These results may be highly clinically significant, because in the United States alone, approximately 10,000 women are diagnosed annually with ERalpha-negative/ERbeta-positive breast carcinoma and may benefit from adjuvant tamoxifen.
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Riggins RB, Schrecengost RS, Guerrero MS, Bouton AH. Pathways to tamoxifen resistance. Cancer Lett 2007; 256:1-24. [PMID: 17475399 PMCID: PMC2533271 DOI: 10.1016/j.canlet.2007.03.016] [Citation(s) in RCA: 198] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Revised: 03/15/2007] [Accepted: 03/15/2007] [Indexed: 02/07/2023]
Abstract
Therapies that target the synthesis of estrogen or the function of estrogen receptor(s) have been developed to treat breast cancer. While these approaches have proven to be beneficial to a large number of patients, both de novo and acquired resistance to these drugs is a significant problem. Recent advances in our understanding of the molecular mechanisms that contribute to resistance have provided a means to begin to predict patient responses to these drugs and develop rational approaches for combining therapeutic agents to circumvent or desensitize the resistant phenotype. Here, we review common mechanisms of antiestrogen resistance and discuss the implications for prediction of response and design of effective combinatorial treatments.
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Affiliation(s)
- Rebecca B. Riggins
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington DC 20057
| | - Randy S. Schrecengost
- Department of Microbiology and Cancer Center, Box 800734, University of Virginia Health System, Charlottesville, VA 22908-0734
| | - Michael S. Guerrero
- Department of Microbiology and Cancer Center, Box 800734, University of Virginia Health System, Charlottesville, VA 22908-0734
| | - Amy H. Bouton
- Department of Microbiology and Cancer Center, Box 800734, University of Virginia Health System, Charlottesville, VA 22908-0734
- Corresponding Author: Amy H. Bouton, e-mail: , Telephone: (434) 924-2513, Fax: (434) 982-1071
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Jerevall PL, Brommesson S, Strand C, Gruvberger-Saal S, Malmström P, Nordenskjöld B, Wingren S, Söderkvist P, Fernö M, Stål O. Exploring the two-gene ratio in breast cancer--independent roles for HOXB13 and IL17BR in prediction of clinical outcome. Breast Cancer Res Treat 2007; 107:225-34. [PMID: 17453342 DOI: 10.1007/s10549-007-9541-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Accepted: 02/12/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND The two-gene expression ratio HOXB13:IL17BR has been proposed to predict the outcome of tamoxifen-treated breast cancer patients. We intended to examine whether this ratio can predict the benefit of 5 years vs. 2 years of tamoxifen treatment of postmenopausal patients. A further objective was to investigate any prognostic effects of the ratio in systematically untreated premenopausal patients. Based on the current knowledge of HOXB13 and IL17BR, we hypothesized that these genes may have individual prognostic or predictive power. PATIENTS AND METHODS Expression of HOXB13 and IL17BR were quantified by real-time PCR in tumors from 264 randomized postmenopausal patients and 93 systemically untreated premenopausal patients. RESULTS A high HOXB13:IL17BR ratio was associated with aggressive tumor characteristics, as were low levels of IL17BR alone. The ratio and HOXB13 alone predicted recurrence-free survival after endocrine treatment, with a benefit of prolonged treatment in estrogen receptor-positive patients correlated to a low ratio (recurrence rate ratio: RR = 0.39; P = 0.030), or low expression of HOXB13 (RR = 0.37; P = 0.015). No difference in recurrence-free survival was seen for the high ratio or high HOXB13 subgroups. The predictive value of HOXB13 and HOXB13:IL17BR was significant in multivariate analysis. In the systemically untreated cohort, only IL17BR showed independent prognostic significance. CONCLUSION We conclude that the ratio or HOXB13 alone can predict the benefit of endocrine therapy, with a high ratio or a high expression rendering patients less likely to respond. We have also shown that IL17BR might be an independent prognostic factor in breast cancer.
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Affiliation(s)
- Piiha-Lotta Jerevall
- Department of Biomedicine and Surgery, Division of Oncology, Linköping University, Linköping, Sweden.
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Ricci MD, Munhoz AM, Pinotti M, Geribela AH, Teixeira LC, Aldrighi C, Ferreira MC, Filassi JR, Pinotti JA. The influence of reduction mammaplasty techniques in synchronous breast cancer diagnosis and metachronous breast cancer prevention. Ann Plast Surg 2007; 57:125-32; discussion 133. [PMID: 16861988 DOI: 10.1097/01.sap.0000216245.16475.b9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although reduction mammaplasty (RM) is a well-described technique for cosmetic objectives, there are few reports regarding its bilateral application combined with oncologic breast surgery in patients with breast cancer. The purpose of this study is to analyze the role of RM in the contralateral breast (CB) synchronous cancer (SBC) incidence, the impact in risk reduction for metachronous breast cancer (MBC), the disease-free period, and overall survival METHODS Patients were divided into 2 groups; group I: 114 pts submitted to oncologic surgery associated with immediate CB RM. Group II: 135 pts without CB RM. Mean time of follow-up was 51.5 months for both groups. Data regarding age, tumor size, histologic type and grade, clinical stage, and adjuvant therapy were collected RESULTS Except for the CB RM, no differences were observed between the groups. In group I, the diagnosis of an occult, synchronic, and invasive carcinoma was noted in 1.8%, in situ in 2.6%, and MBC in 1.8%. In group II, MBC was observed in 6.7%. No difference was observed between the 2 groups (P = 0.062). The initiation of adjuvant therapy, the disease-free period, and overall survival were not influenced by the CB RM. CONCLUSION CB RM is a reliable technique providing an opportunity for diagnosis of an occult SBC. There is evidence of reduction of MBC; however, a larger number of patients are necessary for significant conclusions. The technique should be considered in combination with immediate breast reconstruction. Success depends on patient selection and careful intraoperative management.
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Affiliation(s)
- Marcos Desidério Ricci
- Department of Gynecology and Division of Plastic Surgery, University of São Paulo School of Medicine, São Paulo, Brazil
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Ejlertsen B, Mouridsen HT, Jensen MB, Bengtsson NO, Bergh J, Cold S, Edlund P, Ewertz M, de Graaf PW, Kamby C, Nielsen DL. Similar efficacy for ovarian ablation compared with cyclophosphamide, methotrexate, and fluorouracil: from a randomized comparison of premenopausal patients with node-positive, hormone receptor-positive breast cancer. J Clin Oncol 2006; 24:4956-62. [PMID: 17075113 DOI: 10.1200/jco.2005.05.1235] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To compare the efficacy of ovarian ablation versus chemotherapy in early breast cancer patients with hormone receptor-positive disease. PATIENTS AND METHODS We conducted an open, randomized, multicenter trial including premenopausal breast cancer patients with hormone receptor-positive tumors and either axillary lymph node metastases or tumors with a size of 5 cm or more. Patients were randomly assigned to ovarian ablation by irradiation or to nine courses of chemotherapy with intravenous cyclophosphamide, methotrexate, and fluorouracil (CMF) administered every 3 weeks. RESULTS Between 1990 and May 1998, 762 patients were randomly assigned, and the present analysis is based on 358 first events. After a median follow-up time of 8.5 years, the unadjusted hazard ratio for disease-free survival in the ovarian ablation group compared with the CMF group was 0.99 (95% CI, 0.81 to 1.22). After a median follow-up time of 10.5 years, overall survival (OS) was similar in the two groups, with a hazard ratio of 1.11 (95% CI, 0.88 to 1.42) for the ovarian ablation group compared with the CMF group. CONCLUSION In this study, ablation of ovarian function in premenopausal women with hormone receptor-positive breast cancer had a similar effect to CMF on disease-free and OS. No significant interactions were demonstrated between treatment modality and hormone receptor content, age, or any of the well-known prognostic factors.
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Affiliation(s)
- Bent Ejlertsen
- Department of Oncology, Bldg 5012 Rigshospitalet, Copenhagen University Hospital, DK-2100 Copenhagen, Denmark.
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Longo R, D'Andrea MR, Gasparini G. Sequential Adjuvant Hormone Therapy in Postmenopausal Breast Cancer: Rationale and Clinical Results. Int J Biol Markers 2006; 21:111-22. [PMID: 16847814 DOI: 10.1177/172460080602100207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
For the past 15 years tamoxifen has been the standard adjuvant hormone therapy for women with early-stage breast cancer and estrogen receptor (ER)-positive tumors, irrespective of nodal status and other clinicopathological parameters. Recent studies provided evidence that the optimal duration of tamoxifen treatment is 5 years. Based on the positive clinical results obtained with the administration of aromatase inhibitors (AIs) in the metastatic setting, several controlled clinical trials have evaluated the efficacy and side effects of AIs versus standard tamoxifen also as adjuvant therapy in postmenopausal breast cancer patients. The results of the above studies, suggest a therapeutic advantage of AIs over tamoxifen with regard to relapse-free survival and the risk of metachronous contralateral breast cancer.We review the rationale and the available clinical data on initial or sequential hormone treatment with AIs and we propose a novel scenario for possible therapeutic strategies based on the clinicopathological characteristics of the patients and on the biology of each single tumor.
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Affiliation(s)
- R Longo
- Division of Medical Oncology, S. Filippo Neri Hospital, Rome, Italy
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42
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Jirström K, Rydén L, Anagnostaki L, Nordenskjöld B, Stål O, Thorstenson S, Chebil G, Jönsson PE, Fernö M, Landberg G. Pathology parameters and adjuvant tamoxifen response in a randomised premenopausal breast cancer trial. J Clin Pathol 2006; 58:1135-42. [PMID: 16254100 PMCID: PMC1770762 DOI: 10.1136/jcp.2005.027185] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Subgroups of breast cancer that have an impaired response to endocrine treatment, despite hormone receptor positivity, are still poorly defined. Breast cancer can be subdivided according to standard pathological parameters including histological type, grade, and assessment of proliferation. These parameters are the net result of combinations of genetic alterations effecting tumour behaviour and could potentially reflect subtypes that respond differently to endocrine treatment. AIMS To investigate the usefulness of these parameters as predictors of the response to tamoxifen in premenopausal women with breast cancer. MATERIALS/METHODS Clinically established pathological parameters were assessed and related to the tamoxifen response in 500 available tumour specimens from 564 premenopausal patients with breast cancer randomised to either two years of tamoxifen or no treatment with 14 years of follow up. Proliferation was further evaluated by immunohistochemical Ki-67 expression. RESULTS Oestrogen receptor positive ductal carcinomas responded as expected to tamoxifen, whereas the difference in recurrence free survival between control and tamoxifen treated patients was less apparent in the relatively few lobular carcinomas. For histological grade, there was no obvious difference in treatment response between the groups. The relation between proliferation and tamoxifen response seemed to be more complex, with a clear response in tumours with high and low proliferation, whereas tumours with intermediate proliferation defined by Ki-67 responded more poorly. CONCLUSIONS Clinically established pathology parameters seem to mirror the endocrine treatment response and could potentially be valuable in future treatment decisions for patients with breast cancer.
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MESH Headings
- Adult
- Antineoplastic Agents, Hormonal/therapeutic use
- Biomarkers, Tumor/analysis
- Breast Neoplasms/chemistry
- Breast Neoplasms/drug therapy
- Breast Neoplasms/pathology
- Carcinoma, Ductal, Breast/chemistry
- Carcinoma, Ductal, Breast/drug therapy
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Lobular/chemistry
- Carcinoma, Lobular/drug therapy
- Carcinoma, Lobular/pathology
- Cell Proliferation
- Chemotherapy, Adjuvant
- Female
- Humans
- Ki-67 Antigen/analysis
- Lymphatic Metastasis
- Middle Aged
- Mitotic Index
- Neoplasm Staging
- Premenopause
- Receptors, Estrogen/analysis
- Survival Analysis
- Tamoxifen/therapeutic use
- Treatment Outcome
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Affiliation(s)
- K Jirström
- Division of Pathology Department of Laboratory Medicine, Lund University, Malmö University Hospital, SE-205 02, Malmö, Sweden.
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Dellapasqua S, Castiglione-Gertsch M. Adjuvant endocrine therapies for postmenopausal women with early breast cancer: Standards and not. Breast 2005; 14:555-63. [PMID: 16188442 DOI: 10.1016/j.breast.2005.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Hormonal manipulations have been used for more than 100 years for the treatment of metastatic breast cancer and after definition of the concept of micro-metastases also in the adjuvant setting. In the postmenopausal population, tamoxifen has played the most important role for almost four decades. Progestins or the first generation of aromatase inhibitors (AIs) were only marginally used in the adjuvant setting due to their prohibitive toxicity. The new generation of anti-estrogen compounds, the selective estrogen receptor down-regulators (SERDs) like fulvestrant have a higher affinity for the estrogen receptor than tamoxifen, but none of its agonist activities, and have shown promising clinical activity in the treatment of advanced breast cancer. The third generation of AIs investigated in six large trials has been reported to be superior to tamoxifen in terms of disease-free survival, but not in terms of survival. These trials will be discussed in terms of results in different subpopulations and of toxicity.
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Affiliation(s)
- Silvia Dellapasqua
- International Breast Cancer Study Group (IBCSG) Coordinating Center, Effingerstrasse 40, 3008 Bern, Switzerland
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Cui X, Schiff R, Arpino G, Osborne CK, Lee AV. Biology of progesterone receptor loss in breast cancer and its implications for endocrine therapy. J Clin Oncol 2005; 23:7721-35. [PMID: 16234531 DOI: 10.1200/jco.2005.09.004] [Citation(s) in RCA: 361] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The response to endocrine therapy in breast cancer correlates with estrogen receptor (ER) and progesterone receptor (PR) status. ER-positive/PR-negative breast cancers respond less well to selective ER modulator (SERM) therapy than ER-positive/PR-positive tumors. The predictive value of PR has long been attributed to the dependence of PR expression on ER activity, with the absence of PR reflecting a nonfunctional ER and resistance to hormonal therapy. However, recent clinical and laboratory evidence suggests that ER-positive/PR-negative breast cancers may be specifically resistant to SERMs, whereas they may be less resistant to estrogen withdrawal therapy with aromatase inhibitors, which is a result inconsistent with the nonfunctional ER theory. Novel alternative molecular mechanisms potentially explaining SERM resistance in ER-positive/PR-negative tumors have been suggested by recent experimental indications that growth factors may downregulate PR levels. Thus, the absence of PR may not simply indicate a lack of ER activity, but rather may reflect hyperactive cross talk between ER and growth factor signaling pathways that downregulate PR even as they activate other ER functions. Therefore, ER-positive/PR-negative breast tumors might best be treated by completely blocking ER action via estrogen withdrawal with aromatase inhibitors, by targeted ER degradation, or by combined therapy targeting both ER and growth factor signaling pathways. In this review, we will discuss the biology and etiology of ER-positive/PR-negative breast cancer, highlighting recent data on molecular cross talk between ER and growth factor signaling pathways and demonstrating how PR might be a useful marker of these activities. Finally, we will consider the clinical implications of these observations.
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Affiliation(s)
- Xiaojiang Cui
- Breast Center, Baylor College of Medicine, Houston, TX 77030, USA
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Osborne CK, Schiff R, Arpino G, Lee AS, Hilsenbeck VG. Endocrine responsiveness: understanding how progesterone receptor can be used to select endocrine therapy. Breast 2005; 14:458-65. [PMID: 16236516 DOI: 10.1016/j.breast.2005.08.024] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The receptor for the female hormone progesterone (PR), like that for estrogen (ER), is an important predictive marker for response to endocrine therapy in patients with breast cancer. PR exists as two isoforms, A and B. PR is important in mammary gland development and excess production of PRB is associated with breast cancer risk. Overabundance of PRA is related to resistance to tamoxifen. Total loss of PR is linked to reduced benefit from tamoxifen in both the adjuvant and metastatic settings. The predictive significance of PR expression was originally explained on the basis that PR is an ER-regulated gene and its presence indicates a functioning ER pathway and, therefore, an endocrine-responsive tumor. More recent data, however, suggest an alternative explanation. While many studies show that loss of PR predicts relative resistance to the antiestrogen tamoxifen, a recent study suggests that PR loss may not indicate resistance to aromatase inhibition. The finding that PR loss may not correlate with resistance to aromatase inhibition may be related to crosstalk between ER and PR and growth factor receptor pathways such as HER2. PR loss in some tumors is due to excessive growth factor receptor signaling (overexpression of HER2), which downregulates expression of the PR gene. Neoadjuvant studies also show that HER2 signaling is associated with tamoxifen resistance, but not resistance to aromatase inhibitors. Therefore, high HER2 signaling could explain both PR loss and resistance to tamoxifen while the response to aromatase inhibitors is maintained. In this way, PR loss in some tumors may be a surrogate marker for increased signaling through the growth factor receptor tyrosine kinase pathway and it may help clinicians decide between initial use of an aromatase inhibitor or tamoxifen in the individual patient.
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Affiliation(s)
- C Kent Osborne
- The Breast Center, Baylor College of Medicine, One Baylor Plaza, BCM 600, Houston, TX 77030, USA.
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47
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Huang HJ, Neven P, Drijkoningen M, Paridaens R, Wildiers H, Van Limbergen E, Berteloot P, Amant F, Vergote I, Christiaens MR. Association between tumour characteristics and HER-2/neu by immunohistochemistry in 1362 women with primary operable breast cancer. J Clin Pathol 2005; 58:611-6. [PMID: 15917412 PMCID: PMC1770673 DOI: 10.1136/jcp.2004.022772] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To investigate the association between tumour characteristics and HER-2/neu by immunohistochemistry in primary operable breast cancer. METHODS The association between HER-2/neu and other clinicopathological factors was evaluated in 1362 consecutive patients with primary breast cancer treated between 2000 and July 2003 in one centre. Microscopic tumour size, tumour grade, lymph node status, patient's age, oestrogen receptor (ER), progesterone receptor (PR), and joint ER/PR status were evaluated, using the chi2 test for univariate analysis and logistic regression for multivariate analysis. The hormone receptors and HER-2/neu were studied immunohistochemically. Using the HER-2/neu DAKO scoring system, scores of 0, 1+, or 2+ were defined as negative and 3+ as positive. Data for DAKO scores 2+/3+ versus 0/1+ are also presented. RESULTS Hormone receptor negative breast cancers were more often HER-2/neu positive than hormone receptor positive cancers, both for ER (28.7% v 6.8%) and PR (19.9% v 5.9%). In multivariate analysis, both ER, PR, and tumour grade were independently associated with HER-2/neu. In ER+ tumours, HER-2/neu overexpression was significantly lower in PR+ than in PR- cases (11.5% v 5.4%). HER-2/neu overexpression (2.7%) was lowest in the large subgroup of ER+PR+ tumours with low tumour grade (grade 1-2), comprising 46.1% of all patients. CONCLUSIONS ER, PR, and tumour grade are independent predictors for HER-2/neu overexpression in women with primary operable breast cancer. ER and PR are negatively associated with HER-2/neu, whereas tumour grade is positively associated with HER-2/neu. In women with ER+ tumours, PR status also affects the likelihood of HER-2/neu expression.
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Affiliation(s)
- H J Huang
- Division of Gynaecological Oncology in Department of Obstetrics and Gynaecology, Chang Gung Memorial Hospital, 333 Taoyuan, Taiwan
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Huang HJ, Neven P, Drijkoningen M, Paridaens R, Wildiers H, Van Limbergen E, Berteloot P, Amant F, Christiaens MR, Vergote I. Association between HER-2/neu and the progesterone receptor in oestrogen-dependent breast cancer is age-related. Breast Cancer Res Treat 2005; 91:81-7. [PMID: 15868434 DOI: 10.1007/s10549-004-8235-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In oestrogen receptor-positive (ER+) breast cancer, HER-2/neu and the progesterone receptor (PR) are inversely associated. This explains a lower response to anti-oestrogens if ER+ breast cancers are HER-2/neu positive. One randomized study however, showed that premenopausal women with an ER+ breast cancer respond to anti-oestrogens independent of HER-2/neu. We therefore hypothesized an age-related association between HER-2/neu and PR in ER+ breast cancers. Receptors for ER, PR and HER-2/neu were analysed by immunohistochemistry (IHC). A uni- and multivariate analyses was carried out to assess this relationship in 1104 women with an ER+ breast cancer. We observed an inverse association between HER-2/neu and PR only after age 45. There were 173 women of age<or=45 and 931 of age>45 years. In multivariate analysis, only tumour grade (p=0.005) but not PR status was associated with HER-2/neu in women age<or=45 years. However, in age>45 years group, both PR status (p=0.001) and tumour grade (p=0.001) were independently associated with HER-2/neu. In ER+ breast cancers from women age>45, PR was positive in 76.9% if HER-2/neu negative but in 53.4% if HER-2/neu positive (p<0.001) and the median quantitative PR levels are 150 and 75 respectively in HER-2/neu negative and HER-2/neu positive tumours (p=0.002). This age effect of HER-2/neu on the PR status was not seen in women age<or=45 years and the median quantitative PR levels are 200 and 220 respectively in HER-2/neu negative and HER-2/neu positive tumours (p=0.518). The study confirms an age-related inverse relationship between HER-2/neu and PR only in women age>45 years but not in women age<or=45 years.
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Affiliation(s)
- Huei-Jean Huang
- Division of Gynaecologic Oncology in Department of Obstetrics and Gynaecology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Colozza M, Larsimont D, Piccart MJ. Progesterone Receptor Testing: Not the Right Time to Be Buried. J Clin Oncol 2005; 23:3867-8; author reply 3869-70. [PMID: 15923594 DOI: 10.1200/jco.2005.05.167] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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50
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Saal LH, Holm K, Maurer M, Memeo L, Su T, Wang X, Yu JS, Malmström PO, Mansukhani M, Enoksson J, Hibshoosh H, Borg A, Parsons R. PIK3CA mutations correlate with hormone receptors, node metastasis, and ERBB2, and are mutually exclusive with PTEN loss in human breast carcinoma. Cancer Res 2005; 65:2554-9. [PMID: 15805248 DOI: 10.1158/0008-5472-can-04-3913] [Citation(s) in RCA: 677] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Deregulation of the phosphatidylinositol 3-kinase (PI3K) pathway either through loss of PTEN or mutation of the catalytic subunit alpha of PI3K (PIK3CA) occurs frequently in human cancer. We identified PIK3CA mutations in 26% of 342 human breast tumor samples and cell lines at about equal frequency in tumor stages I to IV. To investigate the relationship between PTEN and PIK3CA, we generated a cohort of tumors that had lost PTEN expression and compared it with a matched control set that had retained PTEN. A highly significant association between PIK3CA mutations and retention of PTEN protein expression was observed. In addition, PIK3CA mutations were associated with expression of estrogen and progesterone receptors (ER/PR), lymph node metastasis, and ERBB2 overexpression. The fact that PIK3CA mutations and PTEN loss are nearly mutually exclusive implies that deregulated phosphatidylinositol-3,4,5-triphosphate (PIP(3)) is critical for tumorigenesis in a significant fraction of breast cancers and that loss of PIP(3) homeostasis by abrogation of either PIK3CA or PTEN relieves selective pressure for targeting of the other gene. The correlation of PIK3CA mutation to ER/PR-positive tumors and PTEN loss to ER/PR-negative tumors argues for disparate branches of tumor evolution. Furthermore, the association between ERBB2 overexpression and PIK3CA mutation implies that more than one input activating the PI3K/AKT pathway may be required to overcome intact PTEN. Thus, mutation of PIK3CA is frequent, occurs early in carcinoma development, and has prognostic and therapeutic implications.
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Affiliation(s)
- Lao H Saal
- Integrated Program in Cellular, Molecular, and Biophysical Studies, Institute for Cancer Genetics, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA
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