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Chumsri S, Li Z, Serie DJ, Norton N, Mashadi-Hossein A, Tenner K, Brauer HA, Warren S, Danaher P, Colon-Otero G, Partridge AH, Carey LA, Hilbers F, Van Dooren V, Holmes E, Di Cosimo S, Werner O, Huober JB, Dueck AC, Sotiriou C, Saura C, Moreno-Aspitia A, Knutson KL, Perez EA, Thompson EA. Adaptive immune signature in HER2-positive breast cancer in NCCTG (Alliance) N9831 and NeoALTTO trials. NPJ Breast Cancer 2022; 8:68. [PMID: 35610260 PMCID: PMC9130150 DOI: 10.1038/s41523-022-00430-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 03/19/2022] [Indexed: 12/14/2022] Open
Abstract
Trastuzumab acts in part through the adaptive immune system. Previous studies showed that enrichment of immune-related gene expression was associated with improved outcomes in HER2-positive (HER2+) breast cancer. However, the role of the immune system in response to lapatinib is not fully understood. Gene expression analysis was performed in 1,268 samples from the North Central Cancer Treatment Group (NCCTG) N9831 and 244 samples from the NeoALTTO trial. In N9831, enrichment of CD45 and immune-subset signatures were significantly associated with improved outcomes. We identified a novel 17-gene adaptive immune signature (AIS), which was found to be significantly associated with improved RFS among patients who received adjuvant trastuzumab (HR 0.66, 95% CI 0.49-0.90, Cox regression model p = 0.01) but not in patients who received chemotherapy alone (HR 0.96, 95% CI 0.67-1.40, Cox regression model p = 0.97). This result was validated in NeoALTTO. Overall, AIS-low patients had a significantly lower pathologic complete response (pCR) rate compared with AIS-high patients (χ2 p < 0.0001). Among patients who received trastuzumab alone, pCR was observed in 41.7% of AIS-high patients compared with 9.8% in AIS-low patients (OR of 6.61, 95% CI 2.09-25.59, logistic regression model p = 0.003). More importantly, AIS-low patients had a higher pCR rate with an addition of lapatinib (51.1% vs. 9.8%, OR 9.65, 95% CI 3.24-36.09, logistic regression model p < 0.001). AIS-low patients had poor outcomes, despite receiving adjuvant trastuzumab. However, these patients appear to benefit from an addition of lapatinib. Further studies are needed to validate the significance of this signature to identify patients who are more likely to benefit from dual anti-HER2 therapy. ClinicalTrials.gov Identifiers: NCT00005970 (NCCTG N9831) and NCT00553358 (NeoALTTO).
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Affiliation(s)
- Saranya Chumsri
- Jacoby Center for Breast Health, Mayo Clinic, Jacksonville, FL, USA.
| | - Zhuo Li
- Department of Health and Human Services, Mayo Clinic, Jacksonville, FL, USA
| | - Daniel J Serie
- Department of Health and Human Services, Mayo Clinic, Jacksonville, FL, USA
| | - Nadine Norton
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Kathleen Tenner
- Department of Health and Human Services, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | | | - Lisa A Carey
- The University of North Carolina, Chapel Hill, NC, USA
| | | | | | - Eileen Holmes
- The Frontier Science, Perth, UK
- Department of Applied Research and Technological Development, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Serena Di Cosimo
- Department of Applied Research and Technological Development, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Jens Bodo Huober
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Ulm, Ulm, Germany
| | | | | | - Cristina Saura
- Vall d'Hebrón University Hospital, Vall d'Hebron Institute of Oncology (VHIO), SOLTI Breast Cancer Research Group, Barcelona, Spain
| | | | - Keith L Knutson
- Department of Immunology, Mayo Clinic, Jacksonville, FL, USA
| | - Edith A Perez
- Jacoby Center for Breast Health, Mayo Clinic, Jacksonville, FL, USA
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Menendez JA, Lupu R. Fatty acid synthase: A druggable driver of breast cancer brain metastasis. Expert Opin Ther Targets 2022; 26:427-444. [PMID: 35545806 DOI: 10.1080/14728222.2022.2077189] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Brain metastasis (BrM) is a key contributor to morbidity and mortality in breast cancer patients, especially among high-risk epidermal growth factor receptor 2-positive (HER2+) and triple-negative/basal-like molecular subtypes. Optimal management of BrM is focused on characterizing a "BrM dependency map" to prioritize targetable therapeutic vulnerabilities. AREAS COVERED We review recent studies addressing the targeting of BrM in the lipid-deprived brain environment, which selects for brain-tropic breast cancer cells capable of cell-autonomously generating fatty acids by upregulating de novo lipogenesis via fatty acid synthase (FASN). Disruption of FASN activity impairs breast cancer growth in the brain, but not extracranially, and mapping of the molecular causes of organ-specific patterns of metastasis has uncovered an enrichment of lipid metabolism signatures in brain metastasizing cells. Targeting SREBP1-the master regulator of lipogenic gene transcription-curtails the ability of breast cancer cells to survive in the brain microenvironment. EXPERT OPINION Targeting FASN represents a new therapeutic opportunity for patients with breast cancer and BrM. Delivery of brain-permeable FASN inhibitors and identifying strategies to target metabolic plasticity that might compensate for impaired brain FASN activity are two potential roadblocks that may hinder FASN-centered strategies against BrM.
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Affiliation(s)
- Javier A Menendez
- Metabolism and Cancer Group, Program Against Cancer Therapeutic Resistance (ProCURE), Catalan Institute of Oncology, 17007 Girona, Spain.,Girona Biomedical Research Institute (IDIBGI), 17190 Girona, Spain
| | - Ruth Lupu
- Department of Laboratory Medicine and Pathology, Division of Experimental Pathology, Mayo Clinic, Rochester, MN 55905, USA.,Department of Biochemistry and Molecular Biology Laboratory, Mayo Clinic Minnesota, Rochester, MN 55905, USA.,Mayo Clinic Cancer Center, Rochester, MN 55905, USA
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Liu M, Smith R, Liby T, Chiotti K, López CS, Korkola JE. INHBA is a mediator of aggressive tumor behavior in HER2+ basal breast cancer. Breast Cancer Res 2022; 24:18. [PMID: 35248133 PMCID: PMC8898494 DOI: 10.1186/s13058-022-01512-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 02/25/2022] [Indexed: 11/22/2022] Open
Abstract
Background Resistance to HER2-targeted therapeutics remains a significant clinical problem in HER2+ breast cancer patients with advanced disease. This may be particularly true for HER2+ patients with basal subtype disease, as recent evidence suggests they receive limited benefit from standard of care HER2-targeted therapies. Identification of drivers of resistance and aggressive disease that can be targeted clinically has the potential to impact patient outcomes. Methods We performed siRNA knockdown screens of genes differentially expressed between lapatinib-responsive and -resistant HER2+ breast cancer cells, which corresponded largely to luminal versus basal subtypes. We then validated hits in 2-d and 3-d cell culture systems. Results Knockdown of one of the genes, INHBA, significantly slowed growth and increased sensitivity to lapatinib in multiple basal HER2+ cell lines in both 2-d and 3-d cultures, but had no effect in luminal HER2+ cells. Loss of INHBA altered metabolism, eliciting a shift from glycolytic to oxidative phosphorylative metabolism, which was also associated with a decrease in tumor invasiveness. Analysis of breast cancer datasets showed that patients with HER2+ breast cancer and high levels of INHBA expression had worse outcomes than patients with low levels of INHBA expression. Conclusions Our data suggest that INHBA is associated with aggressiveness of the basal subtype of HER2+ tumors, resulting in poor response to HER2-targeted therapy and an invasive phenotype. We hypothesize that targeting this pathway could be an effective therapeutic strategy to reduce invasiveness of tumor cells and to improve therapeutic response. Supplementary Information The online version contains supplementary material available at 10.1186/s13058-022-01512-4.
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Affiliation(s)
- Moqing Liu
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Rebecca Smith
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Tiera Liby
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Kami Chiotti
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, OR, USA
| | - Claudia S López
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA.,Multiscale Microscopy Core, Oregon Health & Science University, Portland, OR, USA
| | - James E Korkola
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA.
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Zhao D, Fu X, Rohr J, Wang Y, Li M, Zhang X, Qin J, Xu M, Li C, Sun G, Wang Z, Guo S. Poor histologic tumor response after adjuvant therapy in basal-like HER2-positive breast carcinoma. Pathol Res Pract 2021; 228:153677. [PMID: 34775151 DOI: 10.1016/j.prp.2021.153677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 10/27/2021] [Accepted: 10/27/2021] [Indexed: 12/21/2022]
Abstract
AIMS HER2-positive breast carcinomas are all treated with first-line anti-HER2 therapy. However, immunohistochemical and molecular profiling demonstrates significant heterogeneity among HER2-positive carcinomas. Basal-like HER2-positive breast carcinomas are poorly differentiated from pure HER2-positive breast carcinomas. MATERIALS AND METHODS Seventy-five patients with HER2-positive, ER- and PR-negative breast carcinomas who received anti-HER2 based neoadjuvant therapy were retrospectively analyzed. Thirty-seven cases were classified as basal-like HER2-positive breast carcinoma with any positivity for CK5/6, and thirty-eight cases were classified as pure HER2-positive breast carcinoma with completely negativity for CK5/6. The clinicopathological features and tumor responses after neoadjuvant therapy and outcomes were analyzed. RESULTS Compared to non-basal HER2-positive breast carcinoma, basal-like HER2-positive breast carcinoma showed distinctive histologic features including poor differentiation and syncytial tumor cells with pushing, invasive borders and a significantly higher proportion of apocrine metaplasia. They also demonstrated significantly higher histologic grade; 18/37 (48.6%) of basal-like carcinomas were grade 3, whereas only 5/38 (13.2%) of non-basal carcinomas were grade 3 (p = 0.001), Furthermore, basal-like HER2-positive breast carcinomas were more likely to be positive or completely negative for p53 (p = 0.009), and demonstrated a higher percentage of TP53 mutation (p = 0.17). These tumors were less responsive to anti-HER2 based neoadjuvant therapy, with Miller-Payne grades 1-3 higher than pure HER2-positive breast carcinoma (25/37 [67.6%] vs 16/38 [42.1%]), and the percentage of grade 4-5 was lower (12/37 [32.4%] vs 22/38 [57.9%]; p = 0.027). CONCLUSIONS Basal-like HER2-positive breast carcinoma has distinctive clinicopathological features and less histologic tumor response after neoadjuvant therapy. There is urgent need to recognize basal-like HER2-positive breast carcinoma to be treated precisely.
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Affiliation(s)
- Danhui Zhao
- Department of Pathology, the First Affinity Hospital of the Air Force Military Medical University, Xi'an, Shaan Xi Province, 710032, China
| | - Xin Fu
- Department of Pathology, the First Affinity Hospital of the Air Force Military Medical University, Xi'an, Shaan Xi Province, 710032, China
| | - Joseph Rohr
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, 68105, NE, USA
| | - Yingmei Wang
- Department of Pathology, the First Affinity Hospital of the Air Force Military Medical University, Xi'an, Shaan Xi Province, 710032, China
| | - Mingyang Li
- Department of Pathology, the First Affinity Hospital of the Air Force Military Medical University, Xi'an, Shaan Xi Province, 710032, China
| | - Xiuming Zhang
- Department of Pathology, the First Affinity Hospital of the Air Force Military Medical University, Xi'an, Shaan Xi Province, 710032, China
| | - Junhui Qin
- Department of Pathology, the First Affinity Hospital of the Air Force Military Medical University, Xi'an, Shaan Xi Province, 710032, China
| | - Mengwei Xu
- Department of Pathology, the First Affinity Hospital of the Air Force Military Medical University, Xi'an, Shaan Xi Province, 710032, China
| | - Chao Li
- Department of Pathology, the First Affinity Hospital of the Air Force Military Medical University, Xi'an, Shaan Xi Province, 710032, China
| | - Guorui Sun
- Department of Pathology, the First Affinity Hospital of the Air Force Military Medical University, Xi'an, Shaan Xi Province, 710032, China
| | - Zhe Wang
- Department of Pathology, the First Affinity Hospital of the Air Force Military Medical University, Xi'an, Shaan Xi Province, 710032, China.
| | - Shuangping Guo
- Department of Pathology, the First Affinity Hospital of the Air Force Military Medical University, Xi'an, Shaan Xi Province, 710032, China.
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Harbeck N, von Schumann R, Kates RE, Braun M, Kuemmel S, Schumacher C, Potenberg J, Malter W, Augustin D, Aktas B, Forstbauer H, Tio J, Grischke EM, Biehl C, Liedtke C, De Haas SL, Deurloo R, Wuerstlein R, Kreipe HH, Gluz O. Immune Markers and Tumor-Related Processes Predict Neoadjuvant Therapy Response in the WSG-ADAPT HER2-Positive/Hormone Receptor-Positive Trial in Early Breast Cancer. Cancers (Basel) 2021; 13:4884. [PMID: 34638369 PMCID: PMC8508505 DOI: 10.3390/cancers13194884] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 11/16/2022] Open
Abstract
Prognostic or predictive biomarkers in HER2-positive early breast cancer (EBC) may inform treatment optimization. The ADAPT HER2-positive/hormone receptor-positive phase II trial (NCT01779206) demonstrated pathological complete response (pCR) rates of ~40% following de-escalated treatment with 12 weeks neoadjuvant ado-trastuzumab emtansine (T-DM1) ± endocrine therapy. In this exploratory analysis, we evaluated potential early predictors of response to neoadjuvant therapy. The effects of PIK3CA mutations and immune (CD8 and PD-L1) and apoptotic markers (BCL2 and MCL1) on pCR rates were assessed, along with intrinsic BC subtypes. Immune response and pCR were lower in PIK3CA-mutated tumors compared with wildtype. Increased BCL2 at baseline in all patients and at Cycle 2 in the T-DM1 arms was associated with lower pCR. In the T-DM1 arms only, the HER2-enriched subtype was associated with increased pCR rate (54% vs. 28%). These findings support further prospective pCR-driven de-escalation studies in patients with HER2-positive EBC.
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Affiliation(s)
- Nadia Harbeck
- Breast Center, Department of Obstetrics and Gynecology and CCCLMU, University of Munich (LMU), Marchioninistrasse 15, 81377 Munich, Germany;
- The West German Study Group, 41061 Mönchengladbach, Germany; (R.E.K.); (O.G.)
| | - Raquel von Schumann
- Evangelical Hospital Bethesda, 41061 Mönchengladbach, Germany; (R.v.S.); (S.K.)
| | - Ronald Ernest Kates
- The West German Study Group, 41061 Mönchengladbach, Germany; (R.E.K.); (O.G.)
| | | | - Sherko Kuemmel
- Evangelical Hospital Bethesda, 41061 Mönchengladbach, Germany; (R.v.S.); (S.K.)
- Breast Unit, Kliniken Essen-Mitte, 45136 Essen, Germany
- Klinik für Gynäkologie mit Brustzentrum Charité-Universitätsmedizin, 10117 Berlin, Germany
| | | | | | - Wolfram Malter
- Breast Center, Department of Obstetrics and Gynecology, University Hospital Cologne, 50937 Cologne, Germany;
| | - Doris Augustin
- Breast Center, Clinic Deggendorf, 94469 Deggendorf, Germany;
| | | | | | - Joke Tio
- University Hospital Münster, 48149 Münster, Germany;
| | | | - Claudia Biehl
- Westphalian Breast Center, City Hospital Dortmund, 44137 Dortmund, Germany;
| | | | | | - Regula Deurloo
- F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland; (S.L.D.H.); (R.D.)
| | - Rachel Wuerstlein
- Breast Center, Department of Obstetrics and Gynecology and CCCLMU, University of Munich (LMU), Marchioninistrasse 15, 81377 Munich, Germany;
| | | | - Oleg Gluz
- The West German Study Group, 41061 Mönchengladbach, Germany; (R.E.K.); (O.G.)
- Evangelical Hospital Bethesda, 41061 Mönchengladbach, Germany; (R.v.S.); (S.K.)
- Breast Center, Department of Obstetrics and Gynecology, University Hospital Cologne, 50937 Cologne, Germany;
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Schettini F, Prat A. Dissecting the biological heterogeneity of HER2-positive breast cancer. Breast 2021; 59:339-350. [PMID: 34392185 PMCID: PMC8374722 DOI: 10.1016/j.breast.2021.07.019] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/19/2021] [Accepted: 07/29/2021] [Indexed: 12/24/2022] Open
Abstract
HER2-positive (HER2+) breast cancer (BC) is a heterogenous and multifaceted disease, with interesting therapeutic implications. First, all intrinsic molecular subtypes can be identified in HER2+ tumors, with the HER2-enriched being the most frequent. Such subtypes do not differ much from their counterparts in HER2-negative disease, apart for the high expression of genes in/near the HER2 amplicon on chromosome 17. Intrinsic subtyping, along with the quantification of ERBB2 mRNA levels, is associated with higher rates of pathologic complete response across neoadjuvant trials of dual HER2 blockade and might help select patients for de-escalation and escalation treatment strategies. Secondly, HER2+ tumors have a broad range of DNA alterations. ERBB2 mutations and alterations in the PI3K/Akt/mTOR pathway are among the most frequent and might predict benefit from potent pan-HER, PI3K and mTOR inhibitors. Moreover, HER2+ tumors are usually infiltrated by lymphocytes. These tumor infiltrating-lymphocytes (TILs) predict response to neoadjuvant anti-HER2-based treatment and exert a prognostic role. PD-L1, detected in ∼42 % of HER2+ BC, might also be useful to define patients responding to novel anti-PD1/PD-L1 immunotherapies. New multiparametric clinicopathologic and genomic tools accounting for this complexity, such as HER2DX, are under development to define more tailored treatment approaches. Finally, HER2-targeted antibody-drug conjugates (ADC) such as trastuzumab deruxtecan might be active in tumors with low expression of HER2. Overall, there is a need to molecularly characterize and develop novel targeted therapies for HER2+ disease. Almost 50 % of HER2+ breast cancer (BC) are molecularly HER2-Enriched (HER2-E). Most relevant mutations are found in ERBB2 (∼4 %) and PI3K/AKT/mTOR pathway (>30 %). Tumor infiltrating lymphocytes are frequent, predictive and prognostic in HER2+ BC. HER2 heterogeneity and HER2 low status are gaining therapeutic relevance. New treatments need to consider HER2+ molecular and microenvironmental complexity.
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Affiliation(s)
- Francesco Schettini
- Translational Genomics and Targeted Therapies in Solid Tumors Group, August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain; SOLTI Breast Cancer Research Group, Barcelona, Spain
| | - Aleix Prat
- Translational Genomics and Targeted Therapies in Solid Tumors Group, August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain; SOLTI Breast Cancer Research Group, Barcelona, Spain; Department of Medical Oncology, Hospital Clinic de Barcelona, Barcelona, Spain; Department of Medicine, University of Barcelona, Barcelona, Spain; Institute of Oncology (IOB)-Quirón, Barcelona, Spain.
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7
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Li Z, Chen S, Feng W, Luo Y, Lai H, Li Q, Xiu B, Li Y, Li Y, Huang S, Zhu X. A pan-cancer analysis of HER2 index revealed transcriptional pattern for precise selection of HER2-targeted therapy. EBioMedicine 2020; 62:103074. [PMID: 33161227 PMCID: PMC7670125 DOI: 10.1016/j.ebiom.2020.103074] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 12/27/2022] Open
Abstract
Background The prevalence of HER2 alterations in pan-cancer indicates a broader range of application of HER2-targeted therapies; however, biomarkers for such therapies are still insufficient and limited to breast cancer and gastric cancer. Methods Using multi-omics data from The Cancer Genome Atlas (TCGA), the landscape of HER2 alterations was exhibited across 33 tumor types. A HER2 index was constructed using one-class logistic regression (OCLR). With the predictive value validated in GEO cohorts and pan-cancer cell lines, the index was then applied to evaluate the HER2-enriched expression pattern across TCGA pan-cancer types. Findings Increased HER2 somatic copy number alterations (SCNAs) could be divided into two patterns, focal- or arm-level. The expression-based HER2 index successfully distinguished the HER2-enriched subtype from the others and provided a stable and superior performance in predicting the response to HER2-targeted therapies both in breast tumor tissue and pan-cancer cell lines. With frequencies varying from 12.0% to 0.9%, tumors including head and neck squamous tumors, gastrointestinal tumors, bladder cancer, lung cancer and uterine tumors exhibited high HER2 indices together with HER2 amplification or overexpression, which may be more suitable for HER2-targeted therapies. The BLCA.3 and HNSC.Basal were the most distinguishable subtypes within bladder cancer and head and neck cancer respectively by HER2 index, implying their potential benefits from HER2-targeted therapies. Interpretation As a pan-cancer predictive biomarker of HER2-targeted therapies, the HER2 index could help identify potential candidates for such treatment in multiple tumor types by combining with HER2 multi-omics features. The discoveries of our study highlight the importance of incorporating transcriptional pattern into the assessment of HER2 status for better patient selection. Funding The National Key Research and Development Program of China; Clinical Research and Cultivation Project of Shanghai ShenKang Hospital Development Center.
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Affiliation(s)
- Ziteng Li
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, and the Shanghai Key Laboratory of Medical Epigenetics, the International Co-laboratory of Medical Epigenetics and Metabolism, Ministry of Science and Technology, Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Siyuan Chen
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, and the Shanghai Key Laboratory of Medical Epigenetics, the International Co-laboratory of Medical Epigenetics and Metabolism, Ministry of Science and Technology, Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wanjing Feng
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, and the Shanghai Key Laboratory of Medical Epigenetics, the International Co-laboratory of Medical Epigenetics and Metabolism, Ministry of Science and Technology, Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yixiao Luo
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, and the Shanghai Key Laboratory of Medical Epigenetics, the International Co-laboratory of Medical Epigenetics and Metabolism, Ministry of Science and Technology, Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hongyan Lai
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, and the Shanghai Key Laboratory of Medical Epigenetics, the International Co-laboratory of Medical Epigenetics and Metabolism, Ministry of Science and Technology, Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, China
| | - Qin Li
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, and the Shanghai Key Laboratory of Medical Epigenetics, the International Co-laboratory of Medical Epigenetics and Metabolism, Ministry of Science and Technology, Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, China
| | - Bingqiu Xiu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yuchen Li
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, and the Shanghai Key Laboratory of Medical Epigenetics, the International Co-laboratory of Medical Epigenetics and Metabolism, Ministry of Science and Technology, Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, China
| | - Yan Li
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, and the Shanghai Key Laboratory of Medical Epigenetics, the International Co-laboratory of Medical Epigenetics and Metabolism, Ministry of Science and Technology, Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shenglin Huang
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, and the Shanghai Key Laboratory of Medical Epigenetics, the International Co-laboratory of Medical Epigenetics and Metabolism, Ministry of Science and Technology, Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Xiaodong Zhu
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, and the Shanghai Key Laboratory of Medical Epigenetics, the International Co-laboratory of Medical Epigenetics and Metabolism, Ministry of Science and Technology, Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
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8
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Kim JY, Park K, Im SA, Jung KH, Sohn J, Lee KS, Kim JH, Yang Y, Park YH. Clinical implications of HER2 mRNA expression and intrinsic subtype in refractory HER2-positive metastatic breast cancer treated with pan-HER inhibitor, poziotinib. Breast Cancer Res Treat 2020; 184:743-753. [PMID: 32860168 DOI: 10.1007/s10549-020-05891-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/17/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION We explored clinical implication of intrinsic molecular subtype in human epidermal growth factor receptor 2 (HER2) + metastatic breast cancer (BC) with pan-HER inhibitor from a phase II clinical trial of poziotinib in refractory HER2+BC patients. METHODS For this translational research correlated with phase II clinical trial, we performed an nCounter expression assay, using gene panel including 50 genes for PAM50 prediction and targeted deep sequencing. RESULTS From 106 participants, we obtained 97 tumor tissues and analyzed gene expression in 91 of these samples. Of 91 HER2+BCs, 40 (44.0%) were HER2-enriched (E) intrinsic molecular subtype, 17 (18.7%) of Luminal A, 16 (17.6%) of Basal-like, 14 (15.4%) of Luminal B and 4 (4.4%) of Normal-like. HER2-E subtype was associated with hormone receptor negativity (odds ratio [OR] 2.93; p = 0.019), 3 + of HER2 immunohistochemistry(IHC) (OR 5.64; p = 0.001), high mRNA expression of HER2 (OR 14.43; p = 0.001) and copy number(CN) amplification of HER2 (OR 12.80; p = 0.005). In genetic alterations, alteration was more frequently observed in HER2-E subtype (OR 3.84; p = 0.022) but there was no association between PIK3CA alteration and HER2-E subtype (p = 0.655). In terms of drug efficacy, high mRNA expression of HER2 was the most powerful predictor of poziotinib response (median progression-free survival [PFS): 4.63 months [high] vs. 2.56 [low]; p < .001). In a combination prediction model, median PFS of intrinsic subtypes except Her2-E with high HER2 mRNA expression without PIK3CA genetic alteration was 6.83 months and that of the remaining group was 1.74 months (p < .001). CONCLUSION HER2-E subtype was associated with hormone receptor status, HER2 IHC, CN and mRNA expression and TP53 mutation. In survival analysis, the information of level of HER2 mRNA expression, intrinsic molecular subtype and PI3K pathway alteration would be independent predictors to poziotinib treatment. ClinicalTrials.gov identifier: NCT02418689.
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Affiliation(s)
- Ji-Yeon Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Kyunghee Park
- Samsung Genome Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Korea
| | - Seock-Ah Im
- Division of Hematology-Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University School of Medicine, Seoul, 03080, Korea
| | - Kyung Hae Jung
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, Korea
| | - Joohyuk Sohn
- Department of Internal Medicine, Yonsei Cancer Center, Seoul, 03722, Korea
| | - Keun Seok Lee
- Center for Breast Cancer, National Cancer Center Hospital, Goyang, 10408, Korea
| | - Jee Hyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, 13620, Korea
| | - Yaewon Yang
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, 28644, Korea
| | - Yeon Hee Park
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea.
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9
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Genomic profiling in oncology clinical practice. Clin Transl Oncol 2020; 22:1430-1439. [PMID: 31981077 DOI: 10.1007/s12094-020-02296-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/08/2020] [Indexed: 02/04/2023]
Abstract
The development of high-throughput technologies such as next-generation sequencing for DNA sequencing together with the decrease in their cost has led to the progressive introduction of genomic profiling in our daily practice in oncology. Nowadays, genomic profiling is part of genetic counseling, cancer diagnosis, molecular characterization, and as a biomarker of prognosis and response to treatment. Furthermore, germline or somatic genomic characterization of the tumor may provide new treatment opportunities for patients with cancer. In this review, we will summarize the clinical applications and limitations of genomic profiling in oncology clinical practice, focusing on next-generation sequencing.
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10
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Kolarova I, Vanasek J, Odrazka K, Melichar B, Ryska A, Petera J, Vosmik M, Dolezel M. Therapeutic significance of hormone receptor positivity in patients with HER-2 positive breast cancer. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2019; 163:285-292. [PMID: 31831888 DOI: 10.5507/bp.2019.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 11/26/2019] [Indexed: 12/21/2022] Open
Abstract
Breast cancer with high expression of human epidermal growth factor receptor (HER)-2 represents a biologically and clinically heterogeneous group of neoplastic disorders. Importantly, hormone receptor expression has an effect on biological properties and affects the selection of therapies. On the basis of molecular genetics, four principal subtypes, including luminal A, luminal B, HER2-enriched (HER-2-E), and basal-like can be distinguished. Breast tumors characterized by HER-2 positivity and simultaneous expression of hormone receptors, triple positive breast cancers (TPBC) are of increasing interest owing to the unique biological characteristics associated with complex interactions between HER-2 and hormone receptor signaling pathways. Interactions between hormone receptors and HER-2 explain the decreased efficacy of hormonal therapy in comparison with HER-2-negative patients. The expression of estrogen receptors in HER-2 positive tumors may also be associated with resistance to anti-HER-2 treatment. Multiple available therapeutic options, including hormonal therapy, anti-HER-2 agents and cytotoxic drugs explain favorable prognosis of TPBC. Escalation and de-escalation therapeutic strategies that could result in lower toxicities are being investigated as well as combinations of anti-HER-2 agents with hormonal therapy, immunotherapy, cyclin dependent kinase 4/6 and phosphatidyl inositol-3-kinase inhibitors. Distinction between subtypes of HER-2-positive breast cancer and treatment diversification may result in improved outcomes in TPBC. A response to neoadjuvant therapy may serve in the tailoring of therapy management.
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Affiliation(s)
- Iveta Kolarova
- Department of Oncology and Radiotherapy, University Hospital Hradec Kralove, Czech Republic.,Faculty of Health Studies, Pardubice University, Pardubice, Czech Republic
| | - Jaroslav Vanasek
- Faculty of Health Studies, Pardubice University, Pardubice, Czech Republic.,Oncology Centre, Multiscan, Pardubice, Czech Republic.,Department of Clinical and Radiation Oncology, Pardubice Hospital, Pardubice, Czech Republic
| | - Karel Odrazka
- Oncology Centre, Multiscan, Pardubice, Czech Republic.,Department of Clinical and Radiation Oncology, Pardubice Hospital, Pardubice, Czech Republic.,Department of Oncology, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Department of Radiotherapy and Oncology, Third Faculty of Medicine, Charles University, Prague, Czech Republic.,Institute for Postgraduate Medical Education, Prague, Czech Republic
| | - Bohuslav Melichar
- Department of Oncology and Radiotherapy, University Hospital Hradec Kralove, Czech Republic.,Department of Oncology and Radiotherapy, Faculty of Medicine in Hradec Kralove, Charles University, Czech Republic.,Department of Oncology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital, Olomouc, Czech Republic
| | - Ales Ryska
- The Fingerland Department of Pathology, Charles University Medical Faculty and University Hospital Hradec Kralove, Czech Republic
| | - Jiri Petera
- Department of Oncology and Radiotherapy, University Hospital Hradec Kralove, Czech Republic.,Department of Oncology and Radiotherapy, Faculty of Medicine in Hradec Kralove, Charles University, Czech Republic
| | - Milan Vosmik
- Department of Oncology and Radiotherapy, University Hospital Hradec Kralove, Czech Republic.,Department of Oncology and Radiotherapy, Faculty of Medicine in Hradec Kralove, Charles University, Czech Republic
| | - Martin Dolezel
- Department of Oncology, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Department of Oncology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital, Olomouc, Czech Republic
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11
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Díaz-Redondo T, Lavado-Valenzuela R, Jimenez B, Pascual T, Gálvez F, Falcón A, Alamo MDC, Morales C, Amerigo M, Pascual J, Sanchez-Muñoz A, González-Guerrero M, Vicioso L, Laborda A, Ortega MV, Perez L, Fernandez-Martinez A, Chic N, Jerez JM, Alvarez M, Prat A, Ribelles N, Alba E. Different Pathological Complete Response Rates According to PAM50 Subtype in HER2+ Breast Cancer Patients Treated With Neoadjuvant Pertuzumab/Trastuzumab vs. Trastuzumab Plus Standard Chemotherapy: An Analysis of Real-World Data. Front Oncol 2019; 9:1178. [PMID: 31750258 PMCID: PMC6848376 DOI: 10.3389/fonc.2019.01178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 10/18/2019] [Indexed: 01/09/2023] Open
Abstract
Background: Double blockade with pertuzumab and trastuzumab combined with chemotherapy is the standard neoadjuvant treatment for HER2-positive early breast cancer. Data derived from clinical trials indicates that the response rates differ among intrinsic subtypes of breast cancer. The aim of this study is to determine if these results are valid in real-world patients. Methods: A total of 259 patients treated in eight Spanish hospitals were included and divided into two cohorts: Cohort A (132 patients) received trastuzumab plus standard neoadjuvant chemotherapy (NAC), and Cohort B received pertuzumab and trastuzumab plus NAC (122 patients). Pathological complete response (pCR) was defined as the complete disappearance of invasive tumor cells. Assignment of the intrinsic subtype was realized using the research-based PAM50 signature. Results: There were more HER2-enriched tumors in Cohort A (70 vs. 56%) and more basal-like tumors in Cohort B (12 vs. 2%), with similar luminal cases in both cohorts (luminal A 12 vs. 14%; luminal B 14 vs. 18%). The overall pCR rate was 39% in Cohort A and 61% in Cohort B. Better pCR rates with pertuzumab plus trastuzumab than with trastuzumab alone were also observed in all intrinsic subtypes (luminal PAM50 41 vs. 11.4% and HER2-enriched subtype 73.5 vs. 50%) but not in basal-like tumors (53.3 vs. 50%). In multivariate analysis the only significant variables related to pCR in both luminal PAM50 and HER2-enriched subtypes were treatment with pertuzumab plus trastuzumab (Cohort B) and histological grade 3. Conclusions: With data obtained from patients treated in clinical practice, it has been possible to verify that the addition of pertuzumab to trastuzumab and neoadjuvant chemotherapy substantially increases the rate of pCR, especially in the HER2-enriched subtype but also in luminal subtypes, with no apparent benefit in basal-like tumors.
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Affiliation(s)
- Tamara Díaz-Redondo
- Instituto de Investigación Biomédica de Málaga (IBIMA), Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
- Unidad de Gestión Clínica Oncología Intercentros, Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
| | - Rocio Lavado-Valenzuela
- Instituto de Investigación Biomédica de Málaga (IBIMA), Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
- Laboratorio de Biología Molecular del Cáncer, Centro de Investigaciones Médico-Sanitarias (CIMES), Universidad de Málaga, Málaga, Spain
| | - Begoña Jimenez
- Instituto de Investigación Biomédica de Málaga (IBIMA), Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
- Unidad de Gestión Clínica Oncología Intercentros, Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
| | - Tomas Pascual
- Translational Genomics and Targeted Therapeutics in Solid Tumors Lab (IDIBAPS), Hospital Clinic de Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | - Alfonso Sanchez-Muñoz
- Instituto de Investigación Biomédica de Málaga (IBIMA), Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
- Unidad de Gestión Clínica Oncología Intercentros, Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
| | | | - Luis Vicioso
- Instituto de Investigación Biomédica de Málaga (IBIMA), Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
- Unidad de Gestión Clínica Anatomía Patológica Intercentros, Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
| | - Aurora Laborda
- Laboratorio de Biología Molecular del Cáncer, Centro de Investigaciones Médico-Sanitarias (CIMES), Universidad de Málaga, Málaga, Spain
| | - Maria Victoria Ortega
- Instituto de Investigación Biomédica de Málaga (IBIMA), Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
- Unidad de Gestión Clínica Anatomía Patológica Intercentros, Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
| | - Lidia Perez
- Instituto de Investigación Biomédica de Málaga (IBIMA), Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
- Unidad de Gestión Clínica Anatomía Patológica Intercentros, Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
| | - Aranzazu Fernandez-Martinez
- Lineberger Comprehensive Cancer Center, University of North Caroina at Chapel Hill, Chapel Hill, NC, United States
| | - Nuria Chic
- Translational Genomics and Targeted Therapeutics in Solid Tumors Lab (IDIBAPS), Hospital Clinic de Barcelona, Barcelona, Spain
| | - Jose Manuel Jerez
- Instituto de Investigación Biomédica de Málaga (IBIMA), Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
- Departamento de Lenguajes y Ciencias de la Computación, Universidad de Málaga, Málaga, Spain
| | - Martina Alvarez
- Instituto de Investigación Biomédica de Málaga (IBIMA), Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
- Laboratorio de Biología Molecular del Cáncer, Centro de Investigaciones Médico-Sanitarias (CIMES), Universidad de Málaga, Málaga, Spain
- Unidad de Gestión Clínica Anatomía Patológica Intercentros, Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
| | - Aleix Prat
- Translational Genomics and Targeted Therapeutics in Solid Tumors Lab (IDIBAPS), Hospital Clinic de Barcelona, Barcelona, Spain
| | - Nuria Ribelles
- Instituto de Investigación Biomédica de Málaga (IBIMA), Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
- Unidad de Gestión Clínica Oncología Intercentros, Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
| | - Emilio Alba
- Instituto de Investigación Biomédica de Málaga (IBIMA), Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
- Unidad de Gestión Clínica Oncología Intercentros, Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
- Laboratorio de Biología Molecular del Cáncer, Centro de Investigaciones Médico-Sanitarias (CIMES), Universidad de Málaga, Málaga, Spain
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12
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Godoy-Ortiz A, Sanchez-Muñoz A, Chica Parrado MR, Álvarez M, Ribelles N, Rueda Dominguez A, Alba E. Deciphering HER2 Breast Cancer Disease: Biological and Clinical Implications. Front Oncol 2019; 9:1124. [PMID: 31737566 PMCID: PMC6828840 DOI: 10.3389/fonc.2019.01124] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 10/09/2019] [Indexed: 12/31/2022] Open
Abstract
The main obstacle for designing effective treatment approaches in breast cancer is the extensive and the characteristic heterogeneity of this tumor. The vast majority of critical genomic changes occurs during breast cancer progression, creating a significant variability within primary tumors as well as between the primary breast cancer and their metastases, a hypothesis have already demonstrated in retrospective studies (1). A clear example of this is the HER2-positive breast cancer. In these tumors, we can find all of the transcriptional subtypes of breast cancer, even the basal like or luminal A subtypes. Although the HER2-enriched is the most representative transcriptional subtype in the HER2-positive breast cancer, we can find it too in breast cancers with HER2-negative status. This intrinsic subtype shows a high expression of the HER2 and is associated with proliferation-related genes clusters, among other features. Therefore, two hypotheses can be suggested. First, the HER2 amplification can be a well-defined driver event present in all of the intrinsic subtypes, and not a subtype marker isolated. Secondly, HER2-enriched subtype can have a distinctive transcriptional landscape independent of HER2 amplification. In this review, we present an extensive revision about the last highlights and advances in clinical and genomic settings of the HER2-positive breast cancer and the HER2-enriched subtype, in an attempt to improving the knowledge of the underlying biology of both entities and to explaining the intrinsic heterogeneity of HER2-positive breast cancers.
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Affiliation(s)
- Ana Godoy-Ortiz
- Unidad de Gestión Clínica Intercentros de Oncología Medica, Hospitales Universitarios Regional y Virgen de la Victoria de Málaga, Málaga, Spain
- Laboratorio de Biología Molecular del Centro de Investigaciones Médico-Sanitarias de Málaga (CIMES), Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), Málaga, Spain
| | - Alfonso Sanchez-Muñoz
- Unidad de Gestión Clínica Intercentros de Oncología Medica, Hospitales Universitarios Regional y Virgen de la Victoria de Málaga, Málaga, Spain
- Laboratorio de Biología Molecular del Centro de Investigaciones Médico-Sanitarias de Málaga (CIMES), Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), Málaga, Spain
| | - Maria Rosario Chica Parrado
- Laboratorio de Biología Molecular del Centro de Investigaciones Médico-Sanitarias de Málaga (CIMES), Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), Málaga, Spain
| | - Martina Álvarez
- Laboratorio de Biología Molecular del Centro de Investigaciones Médico-Sanitarias de Málaga (CIMES), Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), Málaga, Spain
| | - Nuria Ribelles
- Unidad de Gestión Clínica Intercentros de Oncología Medica, Hospitales Universitarios Regional y Virgen de la Victoria de Málaga, Málaga, Spain
- Laboratorio de Biología Molecular del Centro de Investigaciones Médico-Sanitarias de Málaga (CIMES), Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), Málaga, Spain
| | - Antonio Rueda Dominguez
- Unidad de Gestión Clínica Intercentros de Oncología Medica, Hospitales Universitarios Regional y Virgen de la Victoria de Málaga, Málaga, Spain
- Laboratorio de Biología Molecular del Centro de Investigaciones Médico-Sanitarias de Málaga (CIMES), Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), Málaga, Spain
| | - Emilio Alba
- Unidad de Gestión Clínica Intercentros de Oncología Medica, Hospitales Universitarios Regional y Virgen de la Victoria de Málaga, Málaga, Spain
- Laboratorio de Biología Molecular del Centro de Investigaciones Médico-Sanitarias de Málaga (CIMES), Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), Málaga, Spain
- Centro de Investigación Biomédica en Red de Oncología, CIBERONC-ISCIII, Madrid, Spain
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13
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Chumsri S, Li Z, Serie DJ, Mashadi-Hossein A, Colon-Otero G, Song N, Pogue-Geile KL, Gavin PG, Paik S, Moreno-Aspitia A, Perez EA, Thompson EA. Incidence of Late Relapses in Patients With HER2-Positive Breast Cancer Receiving Adjuvant Trastuzumab: Combined Analysis of NCCTG N9831 (Alliance) and NRG Oncology/NSABP B-31. J Clin Oncol 2019; 37:3425-3435. [PMID: 31622131 DOI: 10.1200/jco.19.00443] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Recent trials have shown potential benefit of extended adjuvant endocrine therapy and relatively high risk of recurrence (RoR) after 5 years in hormone receptor-positive (HR+) human epidermal growth factor receptor 2-negative (HER2-) breast cancer. Although risk of late relapse in HR+ HER2- breast cancer is fairly well defined, the risk in HER2-positive (HER2+) breast cancer treated with adjuvant trastuzumab-based chemotherapy remains largely unknown. METHODS We included 3,177 patients with HER2+ breast cancer treated with adjuvant chemotherapy alone or with trastuzumab from the North Central Cancer Treatment Group N9831 (ClinicalTrials.gov identifier: NCT00005970) and National Surgical Adjuvant Breast and Bowel Project B-31 (ClinicalTrials.gov identifier: NCT00004067) trials. RESULTS Overall, HR+ breast cancer was significantly associated with improved recurrence-free survival (RFS) during the first 5 years (hazard ratio, 0.65; 95% CI, 0.56 to 0.77; P < .001). Among patients treated with trastuzumab, cumulative hazard for RFS was lower in patients with HR+ HER2+ breast cancer during the first 5 years (10.96% v 17.48%; hazard ratio, 0.60; 95% CI, 0.45 to 0.79; P < .001). However, there was no significant difference in RFS based on HR status during years 5 to 10 (hazard ratio, 1.32; 95% CI, 0.93 to 1.88; P = .12). A comparable degree of trastuzumab benefit was observed in HR+ and HR- breast cancers ( P for interaction = .87). Furthermore, we observed low RoR in years 5 to 10 among patients with HR+ HER2+ breast cancer: 3.23% in patients without lymph node involvement (N0) and 6.39% in patients with involvement of one to three lymph nodes (N1). CONCLUSION The benefit of adjuvant trastuzumab persists for a long time. A distinct pattern of recurrence was observed between HR+ and HR- HER2+ disease but with similar degree of benefit from adjuvant trastuzumab. RoR in years 5 to 10 in HR+ HER2+ breast cancer is low, particularly in patients with N0 or N1 disease.
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Affiliation(s)
| | - Zhuo Li
- Mayo Clinic, Jacksonville, FL
| | | | | | | | | | | | | | - Soonmyung Paik
- NRG Oncology, Pittsburgh, PA.,Yonsei University College of Medicine, Seoul, Republic of South Korea
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14
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The Dilemma of HER2 Double-equivocal Breast Carcinomas: Genomic Profiling and Implications for Treatment. Am J Surg Pathol 2019; 42:1190-1200. [PMID: 29975246 PMCID: PMC6110371 DOI: 10.1097/pas.0000000000001100] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Supplemental Digital Content is available in the text. The American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) 2013 guidelines for HER2 assessment have increased the number of HER2 equivocal breast carcinomas following in situ hybridization reflex testing, that is, HER2 “double equivocal” (equivocal protein expression and equivocal gene copy number). Forty-five double-equivocal carcinomas were subjected to Prosigna analysis. Twenty-seven cases were investigated for the expression of genes found to be differentially expressed between estrogen receptor (ER)-positive/HER2-positive (N=22) and ER-positive/HER2-negative (N=22) control cases. Twenty-nine of the 45 cases were also analyzed by targeted sequencing using a panel of 14 genes. We then explored the pathologic complete response rates in an independent series of double-equivocal carcinoma patients treated with trastuzumab-containing chemotherapy. All cases were ER-positive, with a mean Ki67 of 28%. Double-equivocal carcinomas were predominantly luminal B (76%); 9 cases (20%) were luminal A, and 2 cases (4%) HER2-enriched. The majority (73%) showed a high risk of recurrence by Prosigna, even when the carcinomas were small (<2 cm), node-negative/micrometastatic, and/or grade 2. Double-equivocal carcinomas showed TP53 (6/29, 20%), PIK3CA (3/29, 10%), HER2 (1/29, 3%), and MAP2K4 (1/29, 3%) mutations. Compared with grade-matched ER-positive/HER2-negative breast carcinomas from METABRIC, double-equivocal carcinomas harbored more frequently TP53 mutations and less frequently PIK3CA mutations (P<0.05). No significant differences were observed with grade-matched ER-positive/HER2-positive carcinomas. Lower pathologic complete response rates were observed in double-equivocal compared with HER2-positive patients (10% vs. 60%, P=0.009). Double-equivocal carcinomas are preferentially luminal B and show a high risk of recurrence. A subset of these tumors can be labeled as HER2-enriched by transcriptomic analysis. HER2 mutations can be identified in HER2 double-equivocal cases.
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15
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Cejalvo JM, Pascual T, Fernández-Martínez A, Brasó-Maristany F, Gomis RR, Perou CM, Muñoz M, Prat A. Clinical implications of the non-luminal intrinsic subtypes in hormone receptor-positive breast cancer. Cancer Treat Rev 2018; 67:63-70. [PMID: 29763779 DOI: 10.1016/j.ctrv.2018.04.015] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/19/2018] [Accepted: 04/20/2018] [Indexed: 12/14/2022]
Abstract
Gene expression profiling has had a considerable impact on our understanding ofbreastcancer biology. Duringthelast decade, 4 intrinsic molecular subtypes of breast cancer (Luminal A, Luminal B, HER2-enriched [HER2-E] and Basal-like) have been identified and intensively studied. In this article, we review and discuss the clinical implications of the 2 non-luminal subtypes (i.e. HER2-E and Basal-like) identified within hormone receptor (HR)-positive disease. After reviewing 32 studies for a total of 13,091 samples, ∼8% and ∼ 15% of early and metastatic HR+/HER2-negative breast cancer, respectively, were found to be non-luminal. Clinically, HR+/HER2-negative/non-luminal subtypes have been associated with estrogen independence, chemo-sensitivity, resistance to CDK4/6 inhibition and poor outcome. Interestingly, EGFR/HER2 tyrosine kinase inhibition might be of value in the HR+/HER2-negative/HER2-E subtype. Finally, the HER2-E subtype within HR+/HER2 + disease represents ∼ 30% and has been associated with anti-HER2 sensitivity, chemo-sensitivity and resistance to CDK4/6 inhibition. In the upcoming years, retrospective and prospective clinical trials evaluating both biomarkers should lead to improvements in patient outcomes.
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Affiliation(s)
- Juan Miguel Cejalvo
- Translational Genomics and Targeted Therapeutics in Solid Tumors, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain; Oncology Program, Institute for Research in Biomedicine (IRB Barcelona) and CIBERONC, Spain
| | - Tomás Pascual
- Translational Genomics and Targeted Therapeutics in Solid Tumors, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain; Department of Medical Oncology, Hospital Clínic de Barcelona, Spain; SOLTI Breast Cancer Cooperative Group, Barcelona, Spain
| | | | - Fara Brasó-Maristany
- Translational Genomics and Targeted Therapeutics in Solid Tumors, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Roger R Gomis
- Oncology Program, Institute for Research in Biomedicine (IRB Barcelona) and CIBERONC, Spain; ICREA, Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain
| | - Charles M Perou
- Department of Genetics, University of North Carolina, Chapel Hill, USA
| | - Montserrat Muñoz
- Translational Genomics and Targeted Therapeutics in Solid Tumors, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain; Department of Medical Oncology, Hospital Clínic de Barcelona, Spain
| | - Aleix Prat
- Translational Genomics and Targeted Therapeutics in Solid Tumors, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain; Department of Medical Oncology, Hospital Clínic de Barcelona, Spain; SOLTI Breast Cancer Cooperative Group, Barcelona, Spain.
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16
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Barroso-Sousa R, Exman P, Tolaney SM. De-escalating treatment in the adjuvant setting in HER2-positive breast cancer. Future Oncol 2018; 14:937-945. [DOI: 10.2217/fon-2017-2500] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The decision to offer adjuvant therapy to patients with early-stage cancer relies on factors related to the risk of disease recurrence, degree of benefit with the proposed therapy and the associated risk of toxicities. For patients with stages II and III HER2-positive breast cancer, administering 1 year of trastuzumab plus comprehensive chemotherapy is the standard of care. However, the pivotal adjuvant trials had very few older patients and patients with small HER2-positive tumors. In this review, we will discuss the clinical data regarding strategies to de-escalate adjuvant systemic therapy in patients with early stage HER2-positive disease.
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Affiliation(s)
- Romualdo Barroso-Sousa
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Pedro Exman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
- Harvard Medical School, Boston, MA 02115, USA
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17
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Daemen A, Manning G. HER2 is not a cancer subtype but rather a pan-cancer event and is highly enriched in AR-driven breast tumors. Breast Cancer Res 2018; 20:8. [PMID: 29382369 PMCID: PMC5791377 DOI: 10.1186/s13058-018-0933-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 01/09/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Approximately one in five breast cancers are driven by amplification and overexpression of the human epidermal growth factor receptor 2 (HER2) receptor kinase, and HER2-enriched (HER2E) is one of four major transcriptional subtypes of breast cancer. We set out to understand the genomics of HER2 amplification independent of subtype, and the underlying drivers and biology of HER2E tumors. METHODS We investigated published genomic data from 3155 breast tumors and 5391 non-breast tumors. RESULTS HER2 amplification is a distinct driver event seen in all breast cancer subtypes, rather than a subtype marker, with major characteristics restricted to amplification and overexpression of HER2 and neighboring genes. The HER2E subtype has a distinctive transcriptional landscape independent of HER2A that reflects androgen receptor signaling as replacement for estrogen receptor (ER)-driven tumorigenesis. HER2 amplification is also an event in 1.8% of non-breast tumors. CONCLUSIONS These discoveries reveal therapeutic opportunities for combining anti-HER2 therapy with anti-androgen agents in breast cancer, and highlight the potential for broader therapeutic use of HER2 inhibitors.
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Affiliation(s)
- Anneleen Daemen
- Bioinformatics & Computational Biology, Genentech, Inc, 1 DNA Way, MS444a, South San Francisco, CA, 94080, USA.
| | - Gerard Manning
- Bioinformatics & Computational Biology, Genentech, Inc, 1 DNA Way, MS444a, South San Francisco, CA, 94080, USA.
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Hollern DP, Swiatnicki MR, Andrechek ER. Histological subtypes of mouse mammary tumors reveal conserved relationships to human cancers. PLoS Genet 2018; 14:e1007135. [PMID: 29346386 PMCID: PMC5773092 DOI: 10.1371/journal.pgen.1007135] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 11/28/2017] [Indexed: 01/03/2023] Open
Abstract
Human breast cancer has been characterized by extensive transcriptional heterogeneity, with dominant patterns reflected in the intrinsic subtypes. Mouse models of breast cancer also have heterogeneous transcriptomes and we noted that specific histological subtypes were associated with particular subsets. We hypothesized that unique sets of genes define each tumor histological type across mouse models of breast cancer. Using mouse models that contained both gene expression data and expert pathologist classification of tumor histology on a sample by sample basis, we predicted and validated gene expression signatures for Papillary, EMT, Microacinar and other histological subtypes. These signatures predict known histological events across murine breast cancer models and identify counterparts of mouse mammary tumor types in subtypes of human breast cancer. Importantly, the EMT, Adenomyoepithelial, and Solid signatures were predictive of clinical events in human breast cancer. In addition, a pan-cancer comparison revealed that the histological signatures were active in a variety of human cancers such as lung, oral, and esophageal squamous tumors. Finally, the differentiation status and transcriptional activity implicit within these signatures was identified. These data reveal that within tumor histology groups are unique gene expression profiles of differentiation and pathway activity that stretch well beyond the transgenic initiating events and that have clear applicability to human cancers. As a result, our work provides a predictive resource and insights into possible mechanisms that govern tumor heterogeneity.
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Affiliation(s)
- Daniel P. Hollern
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States of America
| | - Matthew R. Swiatnicki
- Department of Physiology, Michigan State University, East Lansing, MI, United States of America
| | - Eran R. Andrechek
- Department of Physiology, Michigan State University, East Lansing, MI, United States of America
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Combination Cancer Therapy Can Confer Benefit via Patient-to-Patient Variability without Drug Additivity or Synergy. Cell 2017; 171:1678-1691.e13. [PMID: 29245013 DOI: 10.1016/j.cell.2017.11.009] [Citation(s) in RCA: 402] [Impact Index Per Article: 57.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 07/26/2017] [Accepted: 10/31/2017] [Indexed: 12/20/2022]
Abstract
Combination cancer therapies aim to improve the probability and magnitude of therapeutic responses and reduce the likelihood of acquired resistance in an individual patient. However, drugs are tested in clinical trials on genetically diverse patient populations. We show here that patient-to-patient variability and independent drug action are sufficient to explain the superiority of many FDA-approved drug combinations in the absence of drug synergy or additivity. This is also true for combinations tested in patient-derived tumor xenografts. In a combination exhibiting independent drug action, each patient benefits solely from the drug to which his or her tumor is most sensitive, with no added benefit from other drugs. Even when drug combinations exhibit additivity or synergy in pre-clinical models, patient-to-patient variability and low cross-resistance make independent action the dominant mechanism in clinical populations. This insight represents a different way to interpret trial data and a different way to design combination therapies.
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Predicting the Efficacy of HER2-Targeted Therapies: A Look at the Host. DISEASE MARKERS 2017; 2017:7849108. [PMID: 29403144 PMCID: PMC5748305 DOI: 10.1155/2017/7849108] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 11/21/2017] [Indexed: 12/29/2022]
Abstract
HER2 is overexpressed in 20% of invasive breast cancers (BCs) and correlates with a more aggressive disease. Until the advent of targeted agents, HER2 was associated with worse outcomes. Rationally designed HER2-targeted agents have been developed and introduced into clinical practice for women with HER2-amplified BC, improving disease-free and overall survival for primary and metastatic tumors. Trastuzumab, a recombinant humanized anti-HER2 monoclonal antibody, combined with chemotherapy, remains the standard of care for patients with HER2-positive BCs. However, many patients do not respond to this agent, whereas newer drugs have proven to be efficacious in clinical trials. The identification of biomarkers that select sensitive tumors and patients who will benefit from these new agents would help the incorporation of these therapies, limiting the risk of side effects and overtreatment and improving the outcomes of all patients with early-stage HER2-positive BC. We review the mechanisms of action of HER2-targeting agents, focusing on the involvement of the immune system and related predictive biomarkers.
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Russnes HG, Lingjærde OC, Børresen-Dale AL, Caldas C. Breast Cancer Molecular Stratification: From Intrinsic Subtypes to Integrative Clusters. THE AMERICAN JOURNAL OF PATHOLOGY 2017; 187:2152-2162. [PMID: 28733194 DOI: 10.1016/j.ajpath.2017.04.022] [Citation(s) in RCA: 159] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/19/2017] [Accepted: 04/27/2017] [Indexed: 02/08/2023]
Abstract
Breast carcinomas can be stratified into different entities based on clinical behavior, histologic features, and/or by biological properties. A classification of breast cancer should be based on underlying biology, which we know must be determined by the somatic genomic landscape of mutations. Moreover, because the latest generations of anticancer agents are founded on biological mechanisms, a detailed molecular stratification is a requirement for appropriate clinical management. Such stratification, based on genomic drivers, will be important for selecting patients for clinical trials. It will also facilitate the discovery of novel drivers, the study of tumor evolution, and the identification of mechanisms of treatment resistance. Assays for risk stratification have focused mainly on response prediction to existing treatment regimens. Molecular stratification based on gene expression profiling revealed that breast cancers could be classified in so-called intrinsic subtypes (luminal A and B, HER2-enriched, basal-like, and normal-like), which mostly corresponded to hormone receptor and HER2 status, and further stratified luminal tumors based on proliferation. The realization that a significant proportion of the gene expression landscape is determined by the somatic copy number alterations that drive expression in cis led to the newer classification of breast cancers into integrative clusters. This stratification of breast cancers into integrative clusters reveals prototypical patterns of single-nucleotide variants and is associated with distinct clinical courses and response to therapy.
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Affiliation(s)
- Hege G Russnes
- Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital Radiumhospitalet, Oslo, Norway; Department of Pathology, Oslo University Hospital Radiumhospitalet, Oslo, Norway
| | - Ole Christian Lingjærde
- Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital Radiumhospitalet, Oslo, Norway; Department of Computer Science, University of Oslo, Oslo, Norway
| | - Anne-Lise Børresen-Dale
- Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital Radiumhospitalet, Oslo, Norway; Department of Medicine, University of Oslo, Oslo, Norway
| | - Carlos Caldas
- Department of Oncology, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, University of Cambridge, Cambridge, United Kingdom.
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Gingras I, Gebhart G, de Azambuja E, Piccart-Gebhart M. HER2-positive breast cancer is lost in translation: time for patient-centered research. Nat Rev Clin Oncol 2017; 14:669-681. [PMID: 28762384 DOI: 10.1038/nrclinonc.2017.96] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
No biomarker beyond HER2 itself, which suffers from a low positive predictive value, has demonstrated clinical utility in breast cancer, despite numerous attempts to improve treatment tailoring for the growing number of anti-HER2 targeted therapies. This prompted us to examine the body of evidence, using a systematic approach, to identify putative predictive biomarkers in HER2-positive breast cancer, and discuss the hitherto failure to address the needs of patients. In the future, it is hoped immune-based biomarkers will predict benefit from anti-HER2 treatments in the neoadjuvant and adjuvant settings. In advanced-stage disease, the quantification of tumour heterogeneity using molecular-imaging technology has generated informative data on the success or failure of the antibody-drug conjugate T-DM1. Treatment tailoring remains a high priority, in cost-constrained health-care systems, but such tailoring will require a dramatic shift in the way translational research is being conducted, with the establishment of large, easily accessible, and well-annotated databases of candidate predictive biomarkers. Single-centre biomarker research should become a thing of the past.
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Affiliation(s)
- Isabelle Gingras
- Department of Hematology and Oncology, Hôpital du Sacré-Coeur de Montréal, 5400 Boulevard Gouin Ouest, H4J 1C5, Montreal, Quebec, Canada
| | - Géraldine Gebhart
- Department of Nuclear Medicine, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B), 1, rue Heger-Bordet, 1000 Brussels, Belgium
| | - Evandro de Azambuja
- Medical Support Team of the Academic Promoting Team (APT), Institut Jules Bordet, Université Libre de Bruxelles (U.L.B), 1, rue Heger-Bordet, 1000 Brussels, Belgium
| | - Martine Piccart-Gebhart
- Department of Medicine, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B), 1, rue Heger-Bordet, 1000 Brussels, Belgium
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HER2-enriched subtype as a predictor of pathological complete response following trastuzumab and lapatinib without chemotherapy in early-stage HER2-positive breast cancer (PAMELA): an open-label, single-group, multicentre, phase 2 trial. Lancet Oncol 2017; 18:545-554. [DOI: 10.1016/s1470-2045(17)30021-9] [Citation(s) in RCA: 196] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 12/24/2016] [Accepted: 01/04/2017] [Indexed: 02/06/2023]
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Pareja F, Marchiò C, Geyer FC, Weigelt B, Reis-Filho JS. Breast Cancer Heterogeneity: Roles in Tumorigenesis and Therapeutic Implications. CURRENT BREAST CANCER REPORTS 2017. [DOI: 10.1007/s12609-017-0233-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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