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Miligy IM, Awasthi R, Mir Y, Khurana A, Sharma V, Chandaran U, Rakha E, Maurice Y, Kearns D, Oweis R, Asar A, Ironside A, Shaaban AM. Morphological and molecular changes of oestrogen receptor-positive breast cancer following bridging endocrine therapy: a United Kingdom multicentre study. Histopathology 2024; 85:405-417. [PMID: 38845397 DOI: 10.1111/his.15238] [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: 01/15/2024] [Revised: 05/21/2024] [Accepted: 05/25/2024] [Indexed: 08/09/2024]
Abstract
AIMS Standard neoadjuvant endocrine therapy (NAET) is used for 6-9 months to downstage hormone-receptor-positive breast cancer. Bridging ET was introduced during the COVID-19 pandemic to delay surgical intervention. There are no data in the literature on the effect of short course therapy on tumour response. We aimed to analyse the effect of bridging ET and validate the previously proposed neoadjuvant ET pathological reporting criteria. METHODS AND RESULTS This was a multicentre cohort of 256 patients who received bridging ET between March and October 2020. Assessment of paired pre- and post-NAET hormone receptors and HER2 and posttherapy Ki67 expression was done. The median duration of NAET was 45 days. In all, 86% of cases achieved partial pathological response and 9% showed minimal residual disease. Histological response to ET was observed from as early as day 6 posttherapy. Central scarring was noted in 32.8% of cases and lymphocytic infiltrate was seen in 43.4% of cases. Significant changes associated with the duration of ET were observed in tumour grade (21%), with downgrading identified in 12% of tumours (P < 0.001), progesterone receptor (PR) expression with switch to PR-negative status in 26% of cases (P < 0.001), and HER2 status with a switch from HER2-low to HER2-negative status in 32% of cases (P < 0.001). The median patient survival was 475 days, with an overall survival rate of 99.6%. CONCLUSIONS Changes characteristic of tumour regression and significant changes in PR and HER2 occurred following a short course of NAET. The findings support biomarker testing on pretreatment core biopsies and retesting following therapy.
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Affiliation(s)
- Islam M Miligy
- Cellular Pathology, Queen Elizabeth Hospital, Birmingham, UK
- Histopathology Department, Menoufia University, Shebin El Kom, Egypt
| | - Rachna Awasthi
- Cellular Pathology, Queen Elizabeth Hospital, Birmingham, UK
| | - Yasmeen Mir
- Pathology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Anuj Khurana
- Pathology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Vijay Sharma
- Pathology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Usha Chandaran
- Histopathology Department, Salford Royal Hospital, Salford, UK
| | - Emad Rakha
- Histopathology Department, Nottingham City Hospital, Nottingham, UK
| | - Yasmine Maurice
- Histopathology Department, Heartlands General Hospital, Birmingham, UK
| | - Daniel Kearns
- Cellular Pathology, Queen Elizabeth Hospital, Birmingham, UK
| | - Rami Oweis
- Histopathology Department, Rotherham Foundation Trust, Rotherham, UK
| | - Amal Asar
- Histopathology Department, Rotherham Foundation Trust, Rotherham, UK
| | | | - Abeer M Shaaban
- Cellular Pathology, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
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Miligy IM, Badr N, Stevens A, Spooner D, Awasthi R, Mir Y, Khurana A, Sharma V, Chandaran U, Rakha EA, Maurice Y, Kearns D, Oweis R, Asar A, Ironside A, Shaaban AM. Pathological Changes Following Neoadjuvant Endocrine Therapy (NAET): A Multicentre Study of 391 Breast Cancers. Int J Mol Sci 2024; 25:7381. [PMID: 39000487 PMCID: PMC11242101 DOI: 10.3390/ijms25137381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 06/30/2024] [Accepted: 07/02/2024] [Indexed: 07/16/2024] Open
Abstract
Oestrogen receptor (ER)-positive breast cancer (BC) is generally well responsive to endocrine therapy. Neoadjuvant endocrine therapy (NAET) is increasingly being used for downstaging ER-positive tumours. This study aims to analyse the effect of NAET on a well-characterised cohort of ER-positive BC with particular emphasis on receptor expression. This is a retrospective United Kingdom (UK) multicentre study of 391 patients who received NAET between October 2012 and October 2020. Detailed analyses of the paired pre- and post-NAET morphological changes and hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) expression were performed. The median duration of NAET was 86 days, with median survival and overall survival rates of 380 days and 93.4%, respectively. A total of 90.3% of cases achieved a pathological partial response, with a significantly higher rate of response in the HER2-low cancers. Following NAET, BC displayed some pathological changes involving the tumour stroma including central scarring and an increase in tumour infiltrating lymphocytes (TILs) and tumour cell morphology. Significant changes associated with the duration of NAET were observed in tumour grade (30.6% of cases), with downgrading identified in 19.3% of tumours (p < 0.001). The conversion of ER status from positive to low or negative was insignificant. The conversion of progesterone receptor (PR) and HER2 status to negative status was observed in 31.3% and 38.1% of cases, respectively (p < 0.001). HER2-low breast cancer decreased from 63% to 37% following NAET in the paired samples. Significant morphological and biomarker changes involving PR and HER2 expression occurred following NAET. The findings support biomarker testing on pre-treatment core biopsies and post-treatment residual carcinoma.
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Affiliation(s)
- Islam M. Miligy
- Cellular Pathology, Queen Elizabeth Hospital, Birmingham B15 2GW, UK; (I.M.M.); (R.A.); (D.K.)
- Histopathology Department, Faculty of Medicine, Menoufia University, Shebin El-Kom 11352, Egypt;
| | - Nahla Badr
- Histopathology Department, Faculty of Medicine, Menoufia University, Shebin El-Kom 11352, Egypt;
| | - Andrea Stevens
- Oncology Department, Queen Elizabeth Hospital, Birmingham B15 2GW, UK; (A.S.); (D.S.)
| | - David Spooner
- Oncology Department, Queen Elizabeth Hospital, Birmingham B15 2GW, UK; (A.S.); (D.S.)
| | - Rachna Awasthi
- Cellular Pathology, Queen Elizabeth Hospital, Birmingham B15 2GW, UK; (I.M.M.); (R.A.); (D.K.)
| | - Yasmeen Mir
- Pathology, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8XP, UK; (Y.M.); (A.K.); (V.S.)
| | - Anuj Khurana
- Pathology, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8XP, UK; (Y.M.); (A.K.); (V.S.)
| | - Vijay Sharma
- Pathology, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8XP, UK; (Y.M.); (A.K.); (V.S.)
| | - Usha Chandaran
- Histopathology Department, Salford Royal Hospital, Salford M6 8HD, UK;
| | - Emad A. Rakha
- Histopathology Department, Nottingham City Hospital, Nottingham NG5 1PB, UK;
| | - Yasmine Maurice
- Histopathology Department, Heartlands General Hospital, Birmingham B9 5SS, UK;
| | - Daniel Kearns
- Cellular Pathology, Queen Elizabeth Hospital, Birmingham B15 2GW, UK; (I.M.M.); (R.A.); (D.K.)
| | - Rami Oweis
- Histopathology Department, Rotherham Foundation Trust, Rotherham S60 2UD, UK; (R.O.); (A.A.)
| | - Amal Asar
- Histopathology Department, Rotherham Foundation Trust, Rotherham S60 2UD, UK; (R.O.); (A.A.)
| | | | - Abeer M. Shaaban
- Cellular Pathology, Queen Elizabeth Hospital, Birmingham B15 2GW, UK; (I.M.M.); (R.A.); (D.K.)
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2SY, UK
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Arshad M, Azad A, Chan PYK, Vigneswara V, Feldinger K, Nafi SNM, Laporte-Maguire E, De Santo C, Zuo J, Shaaban AM, Kong A. Neratinib could be effective as monotherapy or in combination with trastuzumab in HER2-low breast cancer cells and organoid models. Br J Cancer 2024; 130:1990-2002. [PMID: 38600326 PMCID: PMC11182766 DOI: 10.1038/s41416-024-02665-z] [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: 06/13/2023] [Revised: 02/23/2024] [Accepted: 03/19/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Previous studies have suggested that patients with HER2-low breast cancers do not benefit from trastuzumab treatment although the reasons remain unclear. METHODS We investigated the effect of trastuzumab monotherapy and its combination with different HER2 targeting treatments in a panel of breast cancer cell lines and patient-derived organoids (PDOs) using biochemical methods and cell viability assays. RESULTS Compared to sensitive HER2 over-expressing (IHC3 + ) breast cancer cells, increasing doses of trastuzumab could not achieve IC50 in MDA-MB-361 (IHC 2 + FISH + ) and MDA-MB-453 (IHC 2 + FISH-) cells which showed an intermediate response to trastuzumab. Trastuzumab treatment induced upregulation of HER ligand release, resulting in the activation of HER receptors in these cells, which could account for their trastuzumab insensitivity. Adding a dual ADAM10/17 inhibitor to inhibit the shedding of HER ligands in combination with trastuzumab only showed a modest decrease in the cell viability of HER2-low breast cancer cells and PDOs. However, the panHER inhibitor neratinib was an effective monotherapy in HER2-low breast cancer cells and PDOs, and showed additive effects when combined with trastuzumab. CONCLUSION This study demonstrates that neratinib in combination with trastuzumab may be effective in a subset of HER2-low breast cancers although further validation is required in a larger panel of PDOs and in future clinical studies.
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Affiliation(s)
- Maryam Arshad
- Comprehensive Cancer Centre, School of Cancer and Pharmaceutical Sciences, King's College London, London, SE1 1UL, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, B15 2TT, UK
| | - Abul Azad
- Comprehensive Cancer Centre, School of Cancer and Pharmaceutical Sciences, King's College London, London, SE1 1UL, UK
| | - Phoebe Yuen Ka Chan
- Comprehensive Cancer Centre, School of Cancer and Pharmaceutical Sciences, King's College London, London, SE1 1UL, UK
| | - Vasanthy Vigneswara
- Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, B15 2TT, UK
| | - Katharina Feldinger
- Previous association, Department of Molecular Oncology, The Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, OX3 9DS, UK
| | - Siti Norasikin Mohd Nafi
- Department of Pathology, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150, Kota Bharu, Kelantan, Malaysia
| | - Eloise Laporte-Maguire
- Comprehensive Cancer Centre, School of Cancer and Pharmaceutical Sciences, King's College London, London, SE1 1UL, UK
| | - Carmela De Santo
- Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, B15 2TT, UK
| | - Jianmin Zuo
- Institute of Immunology and Immunotherapy, University of Birmingham, Edgbaston, B15 2TT, UK
| | - Abeer M Shaaban
- Department of cellular pathology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Anthony Kong
- Comprehensive Cancer Centre, School of Cancer and Pharmaceutical Sciences, King's College London, London, SE1 1UL, UK.
- Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, B15 2TT, UK.
- Previous association, Department of Molecular Oncology, The Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, OX3 9DS, UK.
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Meneveau MO, Crawford MP, Turkheimer LM, Millard TA, Atkins KA, Showalter SL. The POWER-PAK Score Characterizes Tumor Response to 3 Months of Preoperative Endocrine Therapy. Ann Surg Oncol 2023; 30:6034-6040. [PMID: 37454014 PMCID: PMC10766409 DOI: 10.1245/s10434-023-13892-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/14/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The Pre-Operative Window of Endocrine Therapy to Inform Radiation Therapy Decisions (POWER, NCT04272801) trial aims to determine whether 3 months of preoperative endocrine therapy (pre-ET) informs adjuvant radiation therapy decisions among older women with early stage, ER-positive breast cancer. We propose the POWER Pathologic Assessment and Ki-67 (POWER-PAK) scoring system to characterize the histologic effects of pre-ET. METHODS Histologic evaluation was performed on core biopsy and lumpectomy specimens from 37 POWER trial participants who completed pre-ET and surgery. The POWER-PAK score consists of tumor regression, decrease in Ki-67 expression, and ER expression, each ranging from 0 to 2. Scores were aggregated to create the POWER-PAK score with a range from 0 to 6. Participants with no residual tumor were labelled 6-NRT. RESULTS ER expression did not decrease after pre-ET. Ki-67 decreased from 13% in biopsy specimens to 5% in the lumpectomy specimens (p < 0.001). Cellularity decreased from 40% to 23% (p < 0.001). There was heterogeneity of POWER-PAK scores ranging from 2 to 6-NRT: score of 2, n = 2 (5.4%); 4, n = 8 (21.6%); 5, n = 4 (10.8%); 6, n = 16 (43.2%); and 6-NRT, n = 7 (18.9%). Participants with a score ≥ 5 were more likely to have smaller tumors after pre-ET compared with those with a score < 5 (p = 0.04). CONCLUSIONS The tumor responses following treatment with pre-ET are heterogenous. We propose that the POWER-PAK scoring system can be used to quantify response to pre-ET. Future studies will explore the use of POWER-PAK to support informed decision-making for adjuvant therapy options for older women with early stage breast cancer.
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Affiliation(s)
- Max O Meneveau
- Department of Surgery, Division of Breast and Melanoma Surgery, University of Virginia, Charlottesville, VA, USA
| | - Michael P Crawford
- Department of Pathology, University of Virginia, Charlottesville, VA, USA
| | - Lena M Turkheimer
- Department of Surgery, Division of Breast and Melanoma Surgery, University of Virginia, Charlottesville, VA, USA
| | - Trish A Millard
- Department of Medicine, Division of Hematology/Oncology, University of Virginia, Charlottesville, VA, USA
| | - Kristen A Atkins
- Department of Pathology, University of Virginia, Charlottesville, VA, USA
| | - Shayna L Showalter
- Department of Surgery, Division of Breast and Melanoma Surgery, University of Virginia, Charlottesville, VA, USA.
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Provenzano E, Shaaban AM. Pathology of neoadjuvant therapy and immunotherapy testing for breast cancer. Histopathology 2023; 82:170-188. [PMID: 36482270 DOI: 10.1111/his.14771] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 08/07/2022] [Accepted: 08/08/2022] [Indexed: 12/13/2022]
Abstract
Neoadjuvant chemotherapy (NACT) has become the standard of care for high-risk breast cancer, including triple-negative (TNBC) and HER2-positive disease. As a result, handling and reporting of breast specimens post-NACT is part of routine practice, and it is important for pathologists to recognise the changes in tumour cells, tumour-associated stroma and background breast tissue induced by NACT. Familiarity with characteristic stromal features enables identification of the pre-treatment tumour site and allows confident diagnosis of pathological complete response (pCR) which is important for decisions concerning adjuvant therapy. Neoadjuvant endocrine therapy (NAET) is used less frequently than NACT; however, the SARS-COVID-19 pandemic has changed practice, with increased use as bridging therapy if surgery is delayed. NAET also induces characteristic changes in the tumour and stroma. Changes in the tumour microenvironment following NACT and NAET are also described. Immunotherapy is approved for use in advanced TNBC, and there are several trials exploring its role in early TNBC in the neoadjuvant setting. The current biomarker to determine eligibility for treatment with immune checkpoint inhibitors is programmed death ligand-1 (PD-L1) immunohistochemistry; however, this is complicated by lack of standardisation with different drugs linked to tests using different antibodies with different scoring systems. The situation in the neoadjuvant setting is further complicated by improved pCR rates for PD-L1-positive tumours in both immune therapy and placebo arms. Alternative biomarkers are urgently needed to identify which patients will derive benefit from immunotherapy and key candidates are discussed.
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Affiliation(s)
- Elena Provenzano
- Department of Histopathology, Cambridge University Hospital NHS Foundation Trust and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Abeer M Shaaban
- Queen Elizabeth Hospital Birmingham and University of Birmingham, Birmingham, UK
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