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Doré S, Ali M, Sorin M, McDowell SAC, Desharnais L, Breton V, Yu MW, Arabzadeh A, Ryan MI, Milette S, Quail DF, Walsh LA. Exploring the prognostic significance of arm-level copy number alterations in triple-negative breast cancer. Oncogene 2024; 43:2015-2024. [PMID: 38744952 PMCID: PMC11196216 DOI: 10.1038/s41388-024-03051-y] [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: 07/31/2023] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 05/16/2024]
Abstract
Somatic copy number alterations (SCNAs) are prevalent in cancer and play a significant role in both tumorigenesis and therapeutic resistance. While focal SCNAs have been extensively studied, the impact of larger arm-level SCNAs remains poorly understood. Here, we investigated the association between arm-level SCNAs and overall survival in triple-negative breast cancer (TNBC), an aggressive subtype of breast cancer lacking targeted therapies. We identified frequent arm-level SCNAs, including 21q gain and 7p gain, which correlated with poor overall survival in TNBC patients. Further, we identified the expression of specific genes within these SCNAs associated with survival. Notably, we found that the expression of RIPK4, a gene located on 21q, exhibited a strong correlation with poor overall survival. In functional assays, we demonstrated that targeting Ripk4 in a murine lung metastatic TNBC model significantly reduced tumor burden, improved survival, and increased CD4+ and CD8+ T cell infiltration. RIPK4 enhanced the survival of triple-negative breast cancer cells at secondary sites, thereby facilitating the formation of metastatic lesions. Our findings highlight the significance of arm-level SCNAs in breast cancer progression and identify RIPK4 as a putative driver of TNBC metastasis and immunosuppression.
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Affiliation(s)
- Samuel Doré
- Rosalind and Morris Goodman Cancer Institute, McGill University, Montreal, QC, Canada
- Department of Human Genetics, McGill University, Montreal, QC, Canada
| | - Mariam Ali
- Rosalind and Morris Goodman Cancer Institute, McGill University, Montreal, QC, Canada
- Department of Human Genetics, McGill University, Montreal, QC, Canada
| | - Mark Sorin
- Rosalind and Morris Goodman Cancer Institute, McGill University, Montreal, QC, Canada
- Department of Human Genetics, McGill University, Montreal, QC, Canada
| | - Sheri A C McDowell
- Rosalind and Morris Goodman Cancer Institute, McGill University, Montreal, QC, Canada
- Department of Physiology, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Lysanne Desharnais
- Rosalind and Morris Goodman Cancer Institute, McGill University, Montreal, QC, Canada
- Department of Human Genetics, McGill University, Montreal, QC, Canada
| | - Valérie Breton
- Rosalind and Morris Goodman Cancer Institute, McGill University, Montreal, QC, Canada
- Department of Human Genetics, McGill University, Montreal, QC, Canada
| | - Miranda W Yu
- Rosalind and Morris Goodman Cancer Institute, McGill University, Montreal, QC, Canada
- Department of Physiology, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Azadeh Arabzadeh
- Rosalind and Morris Goodman Cancer Institute, McGill University, Montreal, QC, Canada
| | - Malcolm I Ryan
- Rosalind and Morris Goodman Cancer Institute, McGill University, Montreal, QC, Canada
- Department of Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Simon Milette
- Rosalind and Morris Goodman Cancer Institute, McGill University, Montreal, QC, Canada
- Department of Experimental Medicine, McGill University, Montreal, QC, Canada
| | - Daniela F Quail
- Rosalind and Morris Goodman Cancer Institute, McGill University, Montreal, QC, Canada
- Department of Physiology, Faculty of Medicine, McGill University, Montreal, QC, Canada
- Department of Experimental Medicine, McGill University, Montreal, QC, Canada
| | - Logan A Walsh
- Rosalind and Morris Goodman Cancer Institute, McGill University, Montreal, QC, Canada.
- Department of Human Genetics, McGill University, Montreal, QC, Canada.
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2
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Corredor G, Bharadwaj S, Pathak T, Viswanathan VS, Toro P, Madabhushi A. A Review of AI-Based Radiomics and Computational Pathology Approaches in Triple-Negative Breast Cancer: Current Applications and Perspectives. Clin Breast Cancer 2023; 23:800-812. [PMID: 37380569 PMCID: PMC10733554 DOI: 10.1016/j.clbc.2023.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/30/2023] [Accepted: 06/15/2023] [Indexed: 06/30/2023]
Abstract
Breast cancer is one of the most common and deadly cancers worldwide. Approximately, 20% of all breast cancers are characterized as triple negative (TNBC). TNBC typically is associated with a poorer prognosis relative to other breast cancer subtypes. Due to its aggressiveness and lack of response to hormonal therapy, conventional cytotoxic chemotherapy is the usual treatment; however, this treatment is not always effective, and an important percentage of patients develop recurrence. More recently, immunotherapy has started to be used on some populations with TNBC showing promising results. Unfortunately, immunotherapy is only applicable to a minority of patients and responses in metastatic TNBC have overall been modest in comparison to other cancer types. This situation evidences the need for developing effective biomarkers that help to stratify and personalize patient management. Thanks to recent advances in artificial intelligence (AI), there has been an increasing interest in its use for medical applications aiming at supporting clinical decision making. Several works have used AI in combination with diagnostic medical imaging, more specifically radiology and digitized histopathological tissue samples, aiming to extract disease-specific information that is difficult to quantify by the human eye. These works have demonstrated that analysis of such images in the context of TNBC has great potential for (1) risk-stratifying patients to identify those patients who are more likely to experience disease recurrence or die from the disease and (2) predicting pathologic complete response. In this manuscript, we present an overview on AI and its integration with radiology and histopathological images for developing prognostic and predictive approaches for TNBC. We present state of the art approaches in the literature and discuss the opportunities and challenges with developing AI algorithms regarding further development and clinical deployment, including identifying those patients who may benefit from certain treatments (e.g., adjuvant chemotherapy) from those who may not and thereby should be directed toward other therapies, discovering potential differences between populations, and identifying disease subtypes.
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Affiliation(s)
- Germán Corredor
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA; Louis Stokes Cleveland VA Medical Center, Cleveland, OH
| | - Satvika Bharadwaj
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA
| | - Tilak Pathak
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA
| | - Vidya Sankar Viswanathan
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA
| | | | - Anant Madabhushi
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA; Atlanta VA Medical Center, Atlanta, GA.
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3
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Narod SA, Dent R. Triple-negative breast cancers. Expert Rev Anticancer Ther 2023; 23:1041-1043. [PMID: 37707344 DOI: 10.1080/14737140.2023.2257393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/06/2023] [Indexed: 09/15/2023]
Affiliation(s)
- Steven A Narod
- Women's College Research Institute, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Rebecca Dent
- Department of Medical Oncology, National Cancer Center, Singapore
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4
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Nauwelaers I, Laudus N, Peeters D, Acs B, Denkert C, Michiels S, Horlings H, Siziopikou KP, Ely S, Zardavas D, Mustimbo R, Bartlett J, Floris G, Hartman J, van Deurzen CHM, Ceusters D, Dequeker E, Salgado R. External Quality Assessment 2.0: The Importance of a Standardized Implementation of TILs for Daily and Trial Practices. Cancers (Basel) 2022; 14:cancers14153762. [PMID: 35954426 PMCID: PMC9367276 DOI: 10.3390/cancers14153762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/28/2022] [Indexed: 02/04/2023] Open
Abstract
New assays are developed regularly to improve health care for patients. It is important to ensure that assays are performed correctly. Therefore, it is advised to participate in training and proficiency (competence assessment) programs. Tumor infiltrating lymphocytes (TILs) might improve the estimates of response to therapy and prognosis. Herewith, we propose a new training and proficiency program in which each pathologist can train and test themselves regarding TILs (and PDL1) scoring.
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Affiliation(s)
- Inne Nauwelaers
- Biomedical Quality Assurance Research Unit, Department of Public Health and Primary Care, University of Leuven, Kapucijnenvoer 35d, 3000 Leuven, Belgium; (I.N.); (N.L.); (D.C.); (E.D.)
| | - Nele Laudus
- Biomedical Quality Assurance Research Unit, Department of Public Health and Primary Care, University of Leuven, Kapucijnenvoer 35d, 3000 Leuven, Belgium; (I.N.); (N.L.); (D.C.); (E.D.)
| | - Dieter Peeters
- CellCarta NV, 2610 Antwerp, Belgium;
- Department of Pathology, AZ Sint-Maarten, 2800 Mechelen, Belgium
| | - Balazs Acs
- Department of Oncology and Pathology, Cancer Center Karolinska, Karolinska Institute, 171 64 Stockholm, Sweden; (B.A.); (J.H.)
- Department of Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Carsten Denkert
- Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM), Baldingerstr. 1, 35043 Marburg, Germany;
| | - Stefan Michiels
- Department of Biostatistics and Epidemiology, Gustave Roussy, University Paris-Saclay, 94800 Villejuif, France;
- Oncostat U1018, Inserm, Labeled Ligue Contre le Cancer, University Paris-Saclay, 94800 Villejuif, France
| | - Hugo Horlings
- Division of Molecular Pathology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
- Department of Pathology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Kalliopi P. Siziopikou
- Department of Pathology, Section of Breast Pathology, Northwestern University, Chicago, IL 60611, USA;
| | - Scott Ely
- Translational Medicine, Bristol-Myers Squibb, Princeton, NJ 08540, USA; (S.E.); (R.M.)
| | - Dimitrios Zardavas
- Oncology Clinical Development, Bristol-Myers Squibb, Princeton, NJ 08540, USA;
| | - Roberts Mustimbo
- Translational Medicine, Bristol-Myers Squibb, Princeton, NJ 08540, USA; (S.E.); (R.M.)
| | - John Bartlett
- Edinburgh Cancer Research Centre, Institute of Genetics and Molecular Medicine, Edinburgh EH4 2XR, UK;
| | - Giuseppe Floris
- Laboratory of Translational Cell & Tissue Research, Department of Imaging and Pathology, University of Leuven, 3000 Leuven, Belgium;
- Department of Pathology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Johan Hartman
- Department of Oncology and Pathology, Cancer Center Karolinska, Karolinska Institute, 171 64 Stockholm, Sweden; (B.A.); (J.H.)
- Department of Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | | | - Dorien Ceusters
- Biomedical Quality Assurance Research Unit, Department of Public Health and Primary Care, University of Leuven, Kapucijnenvoer 35d, 3000 Leuven, Belgium; (I.N.); (N.L.); (D.C.); (E.D.)
| | - Els Dequeker
- Biomedical Quality Assurance Research Unit, Department of Public Health and Primary Care, University of Leuven, Kapucijnenvoer 35d, 3000 Leuven, Belgium; (I.N.); (N.L.); (D.C.); (E.D.)
| | - Roberto Salgado
- Department of Pathology, GZA-ZNA Hospitals, 2610 Antwerp, Belgium
- Division of Research, Peter Mac Callum Cancer Centre, Melbourne, VIC 300, Australia
- Correspondence:
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5
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Chen L, Jiang YZ, Wu SY, Wu J, Di GH, Liu GY, Yu KD, Fan L, Li JJ, Hou YF, Hu Z, Chen CM, Huang XY, Cao AY, Hu X, Zhao S, Ma XY, Xu Y, Sun XJ, Chai WJ, Guo X, Chen X, Xu Y, Zhu XY, Zou JJ, Yang WT, Wang ZH, Shao ZM. Famitinib with Camrelizumab and Nab-Paclitaxel for Advanced Immunomodulatory Triple-Negative Breast Cancer (FUTURE-C-Plus): An Open-Label, Single-Arm, Phase II Trial. Clin Cancer Res 2022; 28:2807-2817. [PMID: 35247906 PMCID: PMC9365373 DOI: 10.1158/1078-0432.ccr-21-4313] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/22/2022] [Accepted: 02/28/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Camrelizumab, an mAb against programmed cell death protein 1 (PD-1), plus nab-paclitaxel exhibited promising antitumor activity in refractory metastatic immunomodulatory triple-negative breast cancer (TNBC). Famitinib is a tyrosine kinase inhibitor targeting VEGFR2, PDGFR, and c-kit. We aimed to assess the efficacy and safety of a novel combination of famitinib, camrelizumab, and nab-paclitaxel in advanced immunomodulatory TNBC. PATIENTS AND METHODS This open-label, single-arm, phase II study enrolled patients with previously untreated, advanced, immunomodulatory TNBC (CD8 IHC staining ≥10%). Eligible patients received 20 mg of oral famitinib on days 1 to 28, 200 mg of i.v. camrelizumab on days 1 and 15, and i.v. nab-paclitaxel 100 mg/m2 on days 1, 8, and 15 in 4-week cycles. The primary endpoint was objective response rate (ORR), as assessed by investigators per RECIST v1.1. Key secondary endpoints were progression-free survival (PFS), overall survival (OS), duration of response (DOR), safety, and exploratory biomarkers. RESULTS Forty-eight patients were enrolled and treated. Median follow-up was 17.0 months (range, 8.7-24.3). Confirmed ORR was 81.3% [95% confidence interval (CI), 70.2-92.3], with five complete and 34 partial responses. Median PFS was 13.6 months (95% CI, 8.4-18.8), and median DOR was 14.9 months [95% CI, not estimable (NE)-NE]. Median OS was not reached. No treatment-related deaths were reported. Among 30 patients with IHC, 13 (43.3%) were programmed death-ligand 1 (PD-L1)-negative, and PD-L1 was associated with favorable response. PKD1 and KAT6A somatic mutations were associated with therapy response. CONCLUSIONS The triplet regimen was efficacious and well tolerated in previously untreated, advanced, immunomodulatory TNBC. The randomized controlled FUTURE-SUPER trial is under way to validate our findings. See related commentary by Salgado and Loi, p. 2728.
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Affiliation(s)
- Li Chen
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Yi-Zhou Jiang
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Song-Yang Wu
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Jiong Wu
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Gen-Hong Di
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Guang-Yu Liu
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Ke-Da Yu
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Lei Fan
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Jun-Jie Li
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Yi-Feng Hou
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Zhen Hu
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Can-Ming Chen
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Xiao-Yan Huang
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - A-Yong Cao
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Xin Hu
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Shen Zhao
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Xiao-Yan Ma
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Ying Xu
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Xiang-Jie Sun
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China
| | - Wen-Jun Chai
- Department of Laboratory Animal Science, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China
| | - Xiaomao Guo
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China
| | - Xizi Chen
- Fudan University Shanghai Cancer Center, Institute of Biomedical Sciences, Shanghai Medical College of Fudan University, Shanghai, China
| | - Yanhui Xu
- Fudan University Shanghai Cancer Center, Institute of Biomedical Sciences, Shanghai Medical College of Fudan University, Shanghai, China
| | - Xiao-Yu Zhu
- Jiangsu Hengrui Pharmaceuticals Co. Ltd, Shanghai, China
| | - Jian-Jun Zou
- Jiangsu Hengrui Pharmaceuticals Co. Ltd, Shanghai, China
| | - Wen-Tao Yang
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Corresponding Authors: Zhi-Ming Shao, Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, 270 Dong-An Road, Xuhui District, Shanghai 200032, China. E-mail: ; Zhong-Hua Wang, E-mail: ; and Wen-Tao Yang, Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, 270 Dong-An Road, Xuhui District, Shanghai 200032, China. E-mail:
| | - Zhong-Hua Wang
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China.,Corresponding Authors: Zhi-Ming Shao, Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, 270 Dong-An Road, Xuhui District, Shanghai 200032, China. E-mail: ; Zhong-Hua Wang, E-mail: ; and Wen-Tao Yang, Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, 270 Dong-An Road, Xuhui District, Shanghai 200032, China. E-mail:
| | - Zhi-Ming Shao
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China.,Corresponding Authors: Zhi-Ming Shao, Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, 270 Dong-An Road, Xuhui District, Shanghai 200032, China. E-mail: ; Zhong-Hua Wang, E-mail: ; and Wen-Tao Yang, Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, 270 Dong-An Road, Xuhui District, Shanghai 200032, China. E-mail:
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6
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Bagegni NA, Davis AA, Clifton KK, Ademuyiwa FO. Targeted Treatment for High-Risk Early-Stage Triple-Negative Breast Cancer: Spotlight on Pembrolizumab. BREAST CANCER (DOVE MEDICAL PRESS) 2022; 14:113-123. [PMID: 35515356 PMCID: PMC9064451 DOI: 10.2147/bctt.s293597] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 04/15/2022] [Indexed: 12/31/2022]
Abstract
Triple-negative breast cancer (TNBC) is a biologically aggressive yet heterogeneous disease that disproportionately affects younger women and women of color compared to other breast cancer subtypes. The paucity of effective targeted therapies and the prevalence of chemotherapeutic resistance in high-risk, early-stage TNBC pose significant clinical challenges. Deeper insights into the genomic and immune landscape have revealed key features of TNBC, including intrinsic genomic instability, DNA repair deficiency, and potentially an immunogenic tumor microenvironment. These advances led to landmark trials with immune checkpoint inhibitors in the advanced-stage setting, which subsequently translated into immunotherapy-based clinical trials in the early-stage setting and recent promising results. Pembrolizumab, an anti-programmed death 1 (PD-1) monoclonal antibody, was investigated in combination with platinum-, taxane- and anthracycline-based neoadjuvant chemotherapy followed by adjuvant pembrolizumab monotherapy for patients with high-risk, early-stage TNBC in the randomized, double-blind, placebo-controlled phase 3 KEYNOTE-522 trial. In July 2021, the US Food and Drug Administration (FDA) granted approval for pembrolizumab based on marked improvement in pathologic complete response rate and 3-year event-free survival compared to neoadjuvant chemotherapy alone. This advance immediately altered the longstanding treatment paradigm. Here, we review the impact of pembrolizumab plus chemotherapy for the treatment of patients with high-risk, early-stage TNBC, and discuss immunotherapy-related toxicity considerations, key immunomodulatory biomarkers under active investigation, and remaining clinical questions for future research directions.
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Affiliation(s)
- Nusayba A Bagegni
- Division of Oncology, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, MO, 63110, USA
| | - Andrew A Davis
- Division of Oncology, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, MO, 63110, USA
| | - Katherine K Clifton
- Division of Oncology, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, MO, 63110, USA
| | - Foluso O Ademuyiwa
- Division of Oncology, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, MO, 63110, USA
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7
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Immune checkpoint inhibition in the treatment of early stage triple negative breast cancer: 2021 update. Breast 2022; 62 Suppl 1:S29-S33. [PMID: 34996667 PMCID: PMC9097806 DOI: 10.1016/j.breast.2021.12.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/24/2021] [Accepted: 12/30/2021] [Indexed: 01/02/2023] Open
Abstract
There is an emerging body of evidence regarding the use of immunotherapy in early-stage triple negative breast cancer (TNBC), with the recent publication of several phase III and randomised phase II studies examining the role of immune checkpoint inhibitors (ICI) in the neoadjuvant setting in combination with chemotherapy. Evidence to date suggests that the addition of PD-1/PD-L1 inhibitors results in slight increases in the rate of pathologic complete response (pCR) seen at the time of surgery, and improved event free survival (EFS) has now been reported. However, a number of questions remain such as the optimal chemotherapy backbone; whether traditional third generation chemotherapy regimens can safely be de-escalated in the presence of an ICI; and the most appropriate sequencing of treatment in order to best harness a durable immune response and if continuation of post operative ICI is needed if one achieves a pCR. A predictive biomarker is also yet to be established, given that PD-L1 protein expression does not seem discriminatory. Given that long-term clinical outcome improvements seen thus far in early stage trials do not seem to be mediated through small changes in pathological complete response rates, new approaches in early stage trial design are now needed.
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8
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Incorporation of TILs in daily breast cancer care: how much evidence can we bear? Virchows Arch 2022; 480:147-162. [PMID: 35043236 DOI: 10.1007/s00428-022-03276-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 01/26/2023]
Abstract
One of the most important developments in the breast cancer field has been an improved understanding of prognostic and predictive biomarkers, of which TILs are increasingly gaining importance. The evaluation of TILs by light microscopy on a H&E-stained section is workable in a daily practice setting. Reproducibility of reporting TILs is good, but heterogeneity is a cause of variation. TILs provide clinicians with important prognostic information for patients with TNBC, as early-stage TNBC with high TILs have > 98% 5-year survival and TILs predict benefit to immunotherapy. Importantly, while TILs do not have level of evidence IA, TILs should be used as a prognostic factor with caution and with other accepted prognostic variables, such as tumour size and lymph node status, to inform clinicians and patients on their treatment options. A framework on how to use the TILs in daily practice is proposed, including a co-assessment with PD-L1 for its predictive role to immunotherapy.
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9
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Liu H, Bai L, Huang L, Ning N, Li L, Li Y, Dong X, Du Q, Xia M, Chen Y, Zhao L, Li Y, Meng Q, Wang J, Duan Y, Ming J, Yuan AQ, Yang XP. Bispecific antibody targeting TROP2xCD3 suppresses tumor growth of triple negative breast cancer. J Immunother Cancer 2021; 9:jitc-2021-003468. [PMID: 34599021 PMCID: PMC8488747 DOI: 10.1136/jitc-2021-003468] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Triple negative breast cancer (TNBC) is a subtype of breast cancers with poor prognosis and targeted drug therapies are limited. To develop novel and efficacious therapies for TNBC, we developed a bispecific antibody F7AK3 that recognizes both trophoblast cell surface antigen 2 (TROP2) and CD3 and evaluated its antitumor activities both in vitro and in vivo. METHODS The binding affinities of F7AK3 to the two targets, TROP2 and CD3, were evaluated by surface plasmon resonance. Binding of F7AK3 to TNBC cells and T cells were evaluated by flow cytometry. Immunofluorescent staining was performed to demonstrate the interactions between T cells with TNBC cells. The cytotoxicity of T cells against TNBC cell lines and primary tumor cells mediated by F7AK3 were determined in vitro. In vivo antitumor activity of F7AK3 was investigated in a xenograft TNBC tumor model, using immunodeficient mice that were reconstituted with human peripheral blood mononuclear cells. RESULTS We demonstrated that F7AK3 binds specifically to human TROP2 and CD3 antigens, as well as TNBC cell lines and primary tumor cells. Human T cells can only be activated by F7AK3 in the presence of target tumor cells. F7AK3 recruits T cells to TROP2+ tumor cells in vitro and into tumor tissues in vivo. Antitumor growth activity of F7AK3 is observed in a xenograft TNBC tumor model. CONCLUSION This study showed the antitumor potential of an anti-TROP2xCD3 bispecific antibody F7AK3 to TNBC tumor cells both in vitro and in vivo. These data demonstrate that F7AK3 has the potential to treat TNBC patients, which warrants further preclinical and clinical evaluation of the F7AK3 in advanced or metastatic TNBC patients.
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Affiliation(s)
- Huicheng Liu
- Department of Immunology, School of Basic Medicine, Huazhong University of Science and Technology Tongji Medical College, Wuhan, Hubei, China
| | - Lili Bai
- Excyte Biopharma Ltd, Beijing, Haidian Dist, China
| | - Liu Huang
- Department of Oncology, Tongji Hospital, Huazhong University of Science and Technology Tongji Medical College, Wuhan, Hubei, China
| | - Na Ning
- Department of Immunology, School of Basic Medicine, Huazhong University of Science and Technology Tongji Medical College, Wuhan, Hubei, China
| | - Lin Li
- Department of Immunology, School of Basic Medicine, Huazhong University of Science and Technology Tongji Medical College, Wuhan, Hubei, China
| | - Yijia Li
- Excyte Biopharma Ltd, Beijing, Haidian Dist, China
| | - Xuejiao Dong
- Department of Immunology, School of Basic Medicine, Huazhong University of Science and Technology Tongji Medical College, Wuhan, Hubei, China
| | - Qiuyang Du
- Department of Immunology, School of Basic Medicine, Huazhong University of Science and Technology Tongji Medical College, Wuhan, Hubei, China
| | - Minghui Xia
- Department of Immunology, School of Basic Medicine, Huazhong University of Science and Technology Tongji Medical College, Wuhan, Hubei, China
| | - Yufei Chen
- Department of Immunology, School of Basic Medicine, Huazhong University of Science and Technology Tongji Medical College, Wuhan, Hubei, China
| | - Likun Zhao
- Excyte Biopharma Ltd, Beijing, Haidian Dist, China
| | - Yanhu Li
- Excyte Biopharma Ltd, Beijing, Haidian Dist, China
| | - Qingwu Meng
- Excyte Biopharma Ltd, Beijing, Haidian Dist, China
| | - Jing Wang
- Department of Immunology, School of Basic Medicine, Huazhong University of Science and Technology Tongji Medical College, Wuhan, Hubei, China
| | - Yaqi Duan
- Department of Pathology, School of Basic Medicine, Huazhong University of Science and Technology Tongji Medical College, Wuhan, Hubei, China.,Institute of Pathology, Tongji Hospital, Huazhong University of Science and Technology Tongji Medical College, Wuhan, Hubei, China
| | - Jie Ming
- Department of Breast and Thyroid Surgery, Wuhan Union Hospital, Huazhong University of Science and Technology Tongji Medical College, Wuhan, Hubei, China
| | | | - Xiang-Ping Yang
- Department of Immunology, School of Basic Medicine, Huazhong University of Science and Technology Tongji Medical College, Wuhan, Hubei, China
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10
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Yang X, Weng X, Yang Y, Zhang M, Xiu Y, Peng W, Liao X, Xu M, Sun Y, Liu X. A combined hypoxia and immune gene signature for predicting survival and risk stratification in triple-negative breast cancer. Aging (Albany NY) 2021; 13:19486-19509. [PMID: 34341184 PMCID: PMC8386525 DOI: 10.18632/aging.203360] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023]
Abstract
Background: Increasing evidence showed that the clinical significance of the interaction between hypoxia and immune status in tumor microenvironment. However, reliable biomarkers based on the hypoxia and immune status in triple-negative breast cancer (TNBC) have not been well established. This study aimed to explore a gene signature based on the hypoxia and immune status for predicting prognosis, risk stratification, and individual treatment in TNBC. Methods: Hypoxia-related genes (HRGs) and Immune-related genes (IRGs) were identified using the weighted gene co-expression network analysis (WGCNA) method and the single-sample gene set enrichment analysis (ssGSEA Z-score) with the transcriptomic profiles from Molecular Taxonomy of Breast Cancer International Consortium (METABRIC) cohort. Then, prognostic hypoxia and immune based genes were identified in TNBC patients from the METABRIC (N = 221), The Cancer Genome Atlas (TCGA) (N = 142), and GSE58812 (N = 107) using univariate cox regression model. A robust hypoxia-immune based gene signature for prognosis was constructed using the least absolute shrinkage and selection operator (LASSO) method. Based on the cross-cohort prognostic hypoxia–immune related gene signature, a comprehensive index of hypoxia and immune was developed and two risk groups with distinct hypoxia–immune status were identified. The prognosis value, hypoxia and immune status, and therapeutic response in different risk groups were analyzed. Furthermore, a nomogram was constructed to predict the prognosis for individual patients, and an independent cohort from the gene expression omnibus (GEO) database was used for external validation. Results: Six cross-cohort prognostic hypoxia–immune related genes were identified to establish the comprehensive index of hypoxia and immune. Then, patients were clustered into high- and low-risk groups based on the hypoxia–immune status. Patients in the high-risk group showed poorer prognoses to their low-risk counterparts, and the nomogram we constructed yielded favorable performance to predict survival and risk stratification. Besides, the high-risk group had a higher expression of hypoxia-related genes and correlated with hypoxia status in tumor microenvironment. The high-risk group had lower fractions of activated immune cells, and exhibited lower expression of immune checkpoint markers. Furthermore, the ratio of complete response (CR) was greatly declined, and the ratio of breast cancer related events were significantly elevated in the high-risk group. Conclusion: The hypoxia–immune based gene signature we constructed for predicting prognosis was developed and validated, which may contribute to the optimization of risk stratification for prognosis and personalized treatment in TNBC patients.
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Affiliation(s)
- Xia Yang
- Department of Pathology, The First Affiliated Hospital of Shen Zhen University, Shenzhen, China.,Department of Pathology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Xin Weng
- Department of Pathology, The First Affiliated Hospital of Shen Zhen University, Shenzhen, China.,Department of Pathology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Yajie Yang
- Department of Pathology, The First Affiliated Hospital of Shen Zhen University, Shenzhen, China.,Department of Pathology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Meng Zhang
- Department of Pathology, The First Affiliated Hospital of Shen Zhen University, Shenzhen, China.,Department of Pathology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Yingjie Xiu
- Department of Pathology, The First Affiliated Hospital of Shen Zhen University, Shenzhen, China.,Department of Pathology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Wenfeng Peng
- Department of Pathology, The First Affiliated Hospital of Shen Zhen University, Shenzhen, China.,Department of Pathology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Xuhui Liao
- Department of Pathology, The First Affiliated Hospital of Shen Zhen University, Shenzhen, China.,Department of Pathology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Meiquan Xu
- Department of Pathology, The First Affiliated Hospital of Shen Zhen University, Shenzhen, China.,Department of Pathology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Yanhua Sun
- Department of Pathology, The First Affiliated Hospital of Shen Zhen University, Shenzhen, China.,Department of Pathology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Xia Liu
- Department of Pathology, The First Affiliated Hospital of Shen Zhen University, Shenzhen, China.,Department of Pathology, Shenzhen Second People's Hospital, Shenzhen, China
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11
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Bevacizumab improves tumor infiltration of mature dendritic cells and effector T-cells in triple-negative breast cancer patients. NPJ Precis Oncol 2021; 5:62. [PMID: 34188163 PMCID: PMC8242049 DOI: 10.1038/s41698-021-00197-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 05/26/2021] [Indexed: 02/08/2023] Open
Abstract
A single dose of bevacizumab reduced the density of angiopoietin-2-positive vessels while improving the infiltration of CD4+ T and CD8+ T cells, and mature dendritic cells in patients with primary triple-negative breast cancer. Our findings provide a rationale for including bevacizumab during neoadjuvant treatment to enhance the efficacy of immune checkpoint blockers in this disease.
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12
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Qi Y, Zhang L, Wang Z, Kong X, Zhai J, Fang Y, Wang J. Efficacy and Safety of Anti-PD-1/ PD-L1 Monotherapy for Metastatic Breast Cancer: Clinical Evidence. Front Pharmacol 2021; 12:653521. [PMID: 34267656 PMCID: PMC8276035 DOI: 10.3389/fphar.2021.653521] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 05/28/2021] [Indexed: 12/31/2022] Open
Abstract
Background: Success has been reported in PD-1/PD-L1 blockade via pembrolizumab, atezolizumab, or avelumab monotherapy in manifold malignancies including metastatic breast cancer. Due to lack of large-scale study, here we present interim analyses to evaluate the safety and efficacy of these promising strategies in patients with advanced breast cancer. Methods: Six studies including 586 advanced breast cancer patients treated with anti-PD-1/PD-L1 monotherapy agents before July 1, 2020, were included. The anti-PD-1/PD-L1 agents include pembrolizumab, atezolizumab, land avelumab. Statistics was analyzed by R software and IBM SPSS Statistics 22. Results: Global analysis showed that for this monotherapy, the complete response was 1.26%, partial response was 7.65%, objective response rate (ORR) was 9.85%, and disease control rate (DCR) was 18.33%. 1-year overall survival rate and 6-month progression-free survival rate were 43.34 and 17.24%. Overall incidence of adverse events (AEs) was 64.18% in any grade and 12.94% in severe grade, while the incidence of immune-related AEs (irAEs) was approximately 14.75%: the most common treatment-related AEs of any grade that occurred in at least 5% of patients were arthralgia and asthenia; the most common severe treatment-related AEs occurred in at least 1% of patients were anemia and autoimmune hepatitis; the most common irAEs were hypothyroidism. Besides, the incidence of discontinue and death due to treatment-related AEs was about 3.06 and 0.31%, respectively. Additionally, by comparing efficacy indicators between PD-L1-positive and PD-L1-negative groups, an implicated correspondence between efficacy and the expression of PD-L1 biomarker was found: the PR was 9.93 vs 2.69%; the ORR was 10.62 vs. 3.07%; the DCR was 17.95 vs. 4.71%. Conclusion: Anti-PD-1/PD-L1 monotherapy showed a manageable safety profile and had a promising and durable anti-tumor efficacy in metastatic breast cancer patients. Higher PD-L1 expression may be closely correlated to a better clinical efficacy.
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Affiliation(s)
- Yihang Qi
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Zhang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia.,Centre of Cancer Research, Victorian Comprehensive Cancer Centre, Melbourne, VIC, Australia
| | - Zhongzhao Wang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiangyi Kong
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Zhai
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Fang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Wang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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13
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Thagaard J, Stovgaard ES, Vognsen LG, Hauberg S, Dahl A, Ebstrup T, Doré J, Vincentz RE, Jepsen RK, Roslind A, Kümler I, Nielsen D, Balslev E. Automated Quantification of sTIL Density with H&E-Based Digital Image Analysis Has Prognostic Potential in Triple-Negative Breast Cancers. Cancers (Basel) 2021; 13:3050. [PMID: 34207414 PMCID: PMC8235502 DOI: 10.3390/cancers13123050] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/15/2021] [Accepted: 06/17/2021] [Indexed: 12/18/2022] Open
Abstract
Triple-negative breast cancer (TNBC) is an aggressive and difficult-to-treat cancer type that represents approximately 15% of all breast cancers. Recently, stromal tumor-infiltrating lymphocytes (sTIL) resurfaced as a strong prognostic biomarker for overall survival (OS) for TNBC patients. Manual assessment has innate limitations that hinder clinical adoption, and the International Immuno-Oncology Biomarker Working Group (TIL-WG) has therefore envisioned that computational assessment of sTIL could overcome these limitations and recommended that any algorithm should follow the manual guidelines where appropriate. However, no existing studies capture all the concepts of the guideline or have shown the same prognostic evidence as manual assessment. In this study, we present a fully automated digital image analysis pipeline and demonstrate that our hematoxylin and eosin (H&E)-based pipeline can provide a quantitative and interpretable score that correlates with the manual pathologist-derived sTIL status, and importantly, can stratify a retrospective cohort into two significant distinct prognostic groups. We found our score to be prognostic for OS (HR: 0.81 CI: 0.72-0.92 p = 0.001) independent of age, tumor size, nodal status, and tumor type in statistical modeling. While prior studies have followed fragments of the TIL-WG guideline, our approach is the first to follow all complex aspects, where appropriate, supporting the TIL-WG vision of computational assessment of sTIL in the future clinical setting.
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Affiliation(s)
- Jeppe Thagaard
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark; (L.G.V.); (S.H.); (A.D.)
- Visiopharm A/S, 2970 Hørsholm, Denmark; (T.E.); (J.D.)
| | - Elisabeth Specht Stovgaard
- Department of Pathology, Herlev and Gentofte Hospital, 2730 Herlev, Denmark; (E.S.S.); (R.E.V.); (R.K.J.); (A.R.); (E.B.)
| | - Line Grove Vognsen
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark; (L.G.V.); (S.H.); (A.D.)
- Visiopharm A/S, 2970 Hørsholm, Denmark; (T.E.); (J.D.)
| | - Søren Hauberg
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark; (L.G.V.); (S.H.); (A.D.)
| | - Anders Dahl
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark; (L.G.V.); (S.H.); (A.D.)
| | | | - Johan Doré
- Visiopharm A/S, 2970 Hørsholm, Denmark; (T.E.); (J.D.)
| | - Rikke Egede Vincentz
- Department of Pathology, Herlev and Gentofte Hospital, 2730 Herlev, Denmark; (E.S.S.); (R.E.V.); (R.K.J.); (A.R.); (E.B.)
| | - Rikke Karlin Jepsen
- Department of Pathology, Herlev and Gentofte Hospital, 2730 Herlev, Denmark; (E.S.S.); (R.E.V.); (R.K.J.); (A.R.); (E.B.)
| | - Anne Roslind
- Department of Pathology, Herlev and Gentofte Hospital, 2730 Herlev, Denmark; (E.S.S.); (R.E.V.); (R.K.J.); (A.R.); (E.B.)
| | - Iben Kümler
- Department of Oncology, Herlev and Gentofte Hospital, 2730 Herlev, Denmark; (I.K.); (D.N.)
| | - Dorte Nielsen
- Department of Oncology, Herlev and Gentofte Hospital, 2730 Herlev, Denmark; (I.K.); (D.N.)
| | - Eva Balslev
- Department of Pathology, Herlev and Gentofte Hospital, 2730 Herlev, Denmark; (E.S.S.); (R.E.V.); (R.K.J.); (A.R.); (E.B.)
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