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Verschoor N, Bos MK, de Kruijff IE, Van MN, Kraan J, Drooger JC, Zuetenhorst JM, Wilting SM, Sleijfer S, Jager A, Martens JWM. Trastuzumab and first-line taxane chemotherapy in metastatic breast cancer patients with a HER2-negative tumor and HER2-positive circulating tumor cells: a phase II trial. Breast Cancer Res Treat 2024; 205:87-95. [PMID: 38291268 PMCID: PMC11062986 DOI: 10.1007/s10549-023-07231-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/11/2023] [Indexed: 02/01/2024]
Abstract
PURPOSE HER2 overexpressing circulating tumor cells (CTCs) are observed in up to 25% of HER2-negative metastatic breast cancer patients. Since targeted anti-HER2 therapy has drastically improved clinical outcomes of patients with HER2-positive breast cancer, we hypothesized that patients with HER2 overexpressing CTCs might benefit from the addition of trastuzumab to chemotherapy. METHODS In this single-arm, phase II trial, patients with HER2-positive CTCs received trastuzumab as addition to first-line treatment with taxane chemotherapy. Patients with detectable CTCs but without HER2 overexpression that received taxane chemotherapy only, were used as control group. The primary outcome measure was progression-free rate at 6 months (PFR6), with a target of 80%. In November 2022, the study was terminated early due to slow patient accrual. RESULTS 63 patients were screened, of which eight patients had HER2-positive CTCs and were treated with trastuzumab. The median number of CTCs was 15 per 7.5 ml of blood (range 1-131) in patients with HER2-positive CTCs, compared to median 5 (range 1-1047) in the control group. PFR6 was 50% in the trastuzumab group and 54% in the taxane monotherapy group, with no significant difference in median PFS (8 versus 9 months, p = 0.51). CONCLUSION No clinical benefit of trastuzumab was observed, although this study was performed in a limited number of patients. Additionally, we observed a strong correlation between the number of evaluable CTCs and the presence of HER2-positive CTCs. We argue that randomized studies investigating agents that are proven to be solely effective in the HER2-positive patient group in patients with HER2-positive CTCs and HER2-negative tissue are currently infeasible. Several factors contribute to this impracticality, including the need for more stringent thresholds, and the rapidly evolving landscape of cancer treatments.
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Affiliation(s)
- Noortje Verschoor
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Manouk K Bos
- Department of Internal Medicine, Breast Cancer Center South Holland South, Ikazia Hospital, Rotterdam, The Netherlands
| | - Ingeborg E de Kruijff
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Mai N Van
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jaco Kraan
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jan C Drooger
- Department of Internal Medicine, Breast Cancer Center South Holland South, Ikazia Hospital, Rotterdam, The Netherlands
| | - Johanna M Zuetenhorst
- Department of Medical Oncology, Franciscus Gasthuis & Vlietland, Rotterdam/Schiedam, The Netherlands
| | - Saskia M Wilting
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Stefan Sleijfer
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - John W M Martens
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Keup C, Kimmig R, Kasimir-Bauer S. The Diversity of Liquid Biopsies and Their Potential in Breast Cancer Management. Cancers (Basel) 2023; 15:5463. [PMID: 38001722 PMCID: PMC10670968 DOI: 10.3390/cancers15225463] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
Analyzing blood as a so-called liquid biopsy in breast cancer (BC) patients has the potential to adapt therapy management. Circulating tumor cells (CTCs), extracellular vesicles (EVs), cell-free DNA (cfDNA) and other blood components mirror the tumoral heterogeneity and could support a range of clinical decisions. Multi-cancer early detection tests utilizing blood are advancing but are not part of any clinical routine yet. Liquid biopsy analysis in the course of neoadjuvant therapy has potential for therapy (de)escalation.Minimal residual disease detection via serial cfDNA analysis is currently on its way. The prognostic value of blood analytes in early and metastatic BC is undisputable, but the value of these prognostic biomarkers for clinical management is controversial. An interventional trial confirmed a significant outcome benefit when therapy was changed in case of newly emerging cfDNA mutations under treatment and thus showed the clinical utility of cfDNA analysis for therapy monitoring. The analysis of PIK3CA or ESR1 variants in plasma of metastatic BC patients to prescribe targeted therapy with alpesilib or elacestrant has already arrived in clinical practice with FDA-approved tests available and is recommended by ASCO. The translation of more liquid biopsy applications into clinical practice is still pending due to a lack of knowledge of the analytes' biology, lack of standards and difficulties in proving clinical utility.
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Affiliation(s)
- Corinna Keup
- Department of Gynecology and Obstetrics, University Hospital of Essen, 45147 Essen, Germany
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3
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Signatures of Breast Cancer Progression in the Blood: What Could Be Learned from Circulating Tumor Cell Transcriptomes. Cancers (Basel) 2022; 14:cancers14225668. [PMID: 36428760 PMCID: PMC9688726 DOI: 10.3390/cancers14225668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 11/19/2022] Open
Abstract
Gene expression profiling has revolutionized our understanding of cancer biology, showing an unprecedented ability to impact patient management especially in breast cancer. The vast majority of breast cancer gene expression signatures derive from the analysis of the tumor bulk, an experimental approach that limits the possibility to dissect breast cancer heterogeneity thoroughly and might miss the message hidden in biologically and clinically relevant cell populations. During disease progression or upon selective pressures, cancer cells undergo continuous transcriptional changes, which inevitably affect tumor heterogeneity, response to therapy and tendency to disseminate. Therefore, metastasis-associated signatures and transcriptome-wide gene expression measurement at single-cell resolution hold great promise for the future of breast cancer clinical care. Seen from this perspective, transcriptomics of circulating tumor cells (CTCs) represent an attractive opportunity to bridge the knowledge gap and develop novel biomarkers. This review summarizes the current state-of-the-science on CTC gene expression analysis in breast cancer, addresses technical and clinical issues related to the application of CTC-derived signatures, and discusses potential research directions.
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Topa J, Grešner P, Żaczek AJ, Markiewicz A. Breast cancer circulating tumor cells with mesenchymal features-an unreachable target? Cell Mol Life Sci 2022; 79:81. [PMID: 35048186 PMCID: PMC8770434 DOI: 10.1007/s00018-021-04064-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 11/26/2021] [Accepted: 11/27/2021] [Indexed: 12/13/2022]
Abstract
Circulating tumor cells (CTCs) mediate dissemination of solid tumors and can be an early sign of disease progression. Moreover, they show a great potential in terms of non-invasive, longitudinal monitoring of cancer patients. CTCs have been extensively studied in breast cancer (BC) and were shown to present a significant phenotypic plasticity connected with initiation of epithelial-mesenchymal transition (EMT). Apart from conferring malignant properties, EMT affects CTCs recovery rate, making a significant portion of CTCs from patients’ samples undetected. Wider application of methods and markers designed to isolate and identify mesenchymal CTCs is required to expand our knowledge about the clinical impact of mesenchymal CTCs. Therefore, here we provide a comprehensive review of clinical significance of mesenchymal CTCs in BC together with statistical analysis of previously published data, in which we assessed the suitability of a number of methods/markers used for isolation of CTCs with different EMT phenotypes, both in in vitro spike-in tests with BC cell lines, as well as clinical samples. Results of spiked-in cell lines indicate that, in general, methods not based on epithelial enrichment only, capture mesenchymal CTCs much more efficiently that CellSearch® (golden standard in CTCs detection), but at the same time are not much inferior to Cell Search®, though large variation in recovery rates of added cells among the methods is observed. In clinical samples, where additional CTCs detection markers are needed, positive epithelial-based CTCs enrichment was the most efficient in isolating CTCs with mesenchymal features from non-metastatic BC patients. From the marker side, PI3K and VIM were contributing the most to detection of CTCs with mesenchymal features (in comparison to SNAIL) in non-metastatic and metastatic BC patients, respectively. However, additional data are needed for more robust identification of markers for efficient detection of CTCs with mesenchymal features.
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Affiliation(s)
- Justyna Topa
- Laboratory of Translational Oncology, Intercollegiate Faculty of Biotechnology, University of Gdańsk and Medical University of Gdańsk, Debinki 1, 80-211, Gdansk, Poland
| | - Peter Grešner
- Laboratory of Translational Oncology, Intercollegiate Faculty of Biotechnology, University of Gdańsk and Medical University of Gdańsk, Debinki 1, 80-211, Gdansk, Poland
| | - Anna J Żaczek
- Laboratory of Translational Oncology, Intercollegiate Faculty of Biotechnology, University of Gdańsk and Medical University of Gdańsk, Debinki 1, 80-211, Gdansk, Poland
| | - Aleksandra Markiewicz
- Laboratory of Translational Oncology, Intercollegiate Faculty of Biotechnology, University of Gdańsk and Medical University of Gdańsk, Debinki 1, 80-211, Gdansk, Poland.
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5
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Strati A, Zavridou M, Kallergi G, Politaki E, Kuske A, Gorges TM, Riethdorf S, Joosse SA, Koch C, Bohnen AL, Mueller V, Koutsodontis G, Kontopodis E, Poulakaki N, Psyrri A, Mavroudis D, Georgoulias V, Pantel K, Lianidou ES. A Comprehensive Molecular Analysis of in Vivo Isolated EpCAM-Positive Circulating Tumor Cells in Breast Cancer. Clin Chem 2021; 67:1395-1405. [PMID: 34322698 DOI: 10.1093/clinchem/hvab099] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/13/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND Circulating tumor cell (CTC) analysis is highly promising for liquid biopsy-based molecular diagnostics. We undertook a comprehensive molecular analysis of in vivo isolated CTCs in breast cancer (BrCa). METHODS In vivo isolated CTCs from 42 patients with early and 23 patients with metastatic breast cancer (MBC) were prospectively collected and analyzed for gene expression, DNA mutations, and DNA methylation before and after treatment. 19 healthy donor (HD) samples were analyzed as a control group. In identical blood draws, CTCs were enumerated using CellSearch® and characterized by direct IF staining. RESULTS All 19 HD samples were negative for CK8, CK18, CK19, ERBB2, TWIST1, VEGF, ESR1, PR, and EGFR expression, while CD44, CD24, ALDH1, VIM, and CDH2 expression was normalized to B2M (reference gene). At least one gene was expressed in 23/42 (54.8%) and 8/13 (61.5%) CTCs in early BrCa before and after therapy, and in 20/23 (87.0%) and 5/7 (71.4%) MBC before and after the first cycle of therapy. PIK3CA mutations were detected in 11/42 (26.2%) and 3/13 (23.1%) in vivo isolated CTCs in early BrCa before and after therapy, and in 11/23 (47.8%) and 2/7 (28.6%) MBC, respectively. ESR1 methylation was detected in 5/32 (15.7%) and 1/10 (10.0%) CTCs in early BrCa before and after therapy, and in 3/15(20.0%) MBC before the first line of therapy. The comprehensive molecular analysis of CTC revealed a higher sensitivity in relation to CellSearch or IF staining when based on creatine kinase selection. CONCLUSIONS In vivo-CTC isolation in combination with a comprehensive molecular analysis at the gene expression, DNA mutation, and DNA methylation level comprises a highly powerful approach for molecular diagnostic applications using CTCs.
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Affiliation(s)
- Areti Strati
- Department of Chemistry, Analysis of Circulating Tumor Cells Laboratory, University of Athens, Greece
| | - Martha Zavridou
- Department of Chemistry, Analysis of Circulating Tumor Cells Laboratory, University of Athens, Greece
| | - Galatea Kallergi
- Laboratory of Τumor Cell Biology, School of Medicine, University of Crete, Heraklion, Crete, Greece.,Division of Genetics, Cell, and Developmental Biology, Department of Biology, University of Patras, Patras, Greece
| | - Eleni Politaki
- Laboratory of Τumor Cell Biology, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Andra Kuske
- Department of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias M Gorges
- Department of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sabine Riethdorf
- Department of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simon A Joosse
- Department of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Claudia Koch
- Department of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna-Lena Bohnen
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Volkmar Mueller
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - George Koutsodontis
- Oncology Unit, Second Department of Internal Medicine, Attikon University Hospital, Haidari, Greece
| | - Emmanouil Kontopodis
- Department of Medical Oncology, University General Hospital of Heraklion, Crete, Greece
| | | | - Amanda Psyrri
- Oncology Unit, Second Department of Internal Medicine, Attikon University Hospital, Haidari, Greece
| | - Dimitris Mavroudis
- Laboratory of Τumor Cell Biology, School of Medicine, University of Crete, Heraklion, Crete, Greece.,Department of Medical Oncology, University General Hospital of Heraklion, Crete, Greece
| | - Vasilis Georgoulias
- Laboratory of Τumor Cell Biology, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Klaus Pantel
- Department of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Evi S Lianidou
- Department of Chemistry, Analysis of Circulating Tumor Cells Laboratory, University of Athens, Greece
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de Kruijff IE, Sieuwerts AM, Beije N, Prager-van der Smissen WJC, Angus L, Beaufort CM, Van MN, Oomen-de Hoop E, Jager A, Hamberg P, de Jongh FE, Kraan J, Martens JWM, Sleijfer S. Prospective Evaluation of a Circulating Tumor Cell Sensitivity Profile to Predict Response to Cisplatin Chemotherapy in Metastatic Breast Cancer Patients. Front Oncol 2021; 11:697572. [PMID: 34249756 PMCID: PMC8269318 DOI: 10.3389/fonc.2021.697572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/27/2021] [Indexed: 11/18/2022] Open
Abstract
Background Cisplatin (cDDP) has regained interest for metastatic breast cancer (MBC) patients, given the platinum sensitivity in subtypes and better manageable toxicity. Here, the primary aim was to determine whether molecular characteristics of circulating tumor cells (CTCs) could identify patients responding to cDDP and to describe the outcomes to cDDP monotherapy in a large group of MBC patients pretreated with anthracycline- and taxane-based treatments. Methods Based on cell line data, a CTC-cDDP-sensitivity profile was generated. Applying an A’Herns single-stage phase II design, further investigation was considered worthwhile if 5/10 patients with a favorable profile responded to cDDP. Patients received 70mg/m2 cDDP every three weeks, CTCs were enumerated and the CTC-cDDP-sensitivity profile was determined. In total, 65 heavily pretreated MBC patients (77% received ≥2 lines of previous chemotherapy for MBC) were eligible for the per-protocol analysis. Primary endpoint was response rate, secondary endpoints included best observed response, progression-free survival (PFS) and overall survival (OS). Results The best observed response during cDDP therapy was a partial response in 7% and stable disease in 56% of the patients. None of the patients with a favorable CTC-cDDP-sensitivity profile had a response. The median baseline CTC count was 8 (range 0-3254). Patients with <5 CTCs had a better PFS and OS than patients with ≥5 CTCs (median PFS 4.5 months (95%CI 2.38-6.62) vs. 2.1 months [(95%CI 1.34-2.80)(p=0.009)] and median OS 13.1 months (95%CI 9.89-16.33) vs. 5.6 months [(95%CI 3.60-7.64)(p=0.003)]. No other factors than CTC count were associated with outcome to cDDP therapy, including triple-negative breast cancer versus ER-positive tumors. Conclusions The CTC-cDDP-sensitivity profile was unable to select patients responding to cDDP monotherapy. In an unselected group of heavily pretreated MBC patients, cDDP yields outcomes comparable to other chemotherapeutic regimens for heavily pretreated MBC patients. CTC count was the only factor associated with outcome in these patients. Clinical Trial Registration (https://www.trialregister.nl/trial/3885, identifier NTR4046)
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Affiliation(s)
- I E de Kruijff
- Department of Medical Oncology & Cancer Genomics Netherlands, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - A M Sieuwerts
- Department of Medical Oncology & Cancer Genomics Netherlands, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - N Beije
- Department of Medical Oncology & Cancer Genomics Netherlands, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - W J C Prager-van der Smissen
- Department of Medical Oncology & Cancer Genomics Netherlands, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - L Angus
- Department of Medical Oncology & Cancer Genomics Netherlands, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - C M Beaufort
- Department of Medical Oncology & Cancer Genomics Netherlands, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - M N Van
- Department of Medical Oncology & Cancer Genomics Netherlands, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - E Oomen-de Hoop
- Department of Medical Oncology & Cancer Genomics Netherlands, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - A Jager
- Department of Medical Oncology & Cancer Genomics Netherlands, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - P Hamberg
- Department of Medical Oncology, Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands
| | - F E de Jongh
- Department of Medical Oncology, Ikazia Ziekenhuis, Rotterdam, Netherlands
| | - J Kraan
- Department of Medical Oncology & Cancer Genomics Netherlands, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - J W M Martens
- Department of Medical Oncology & Cancer Genomics Netherlands, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - S Sleijfer
- Department of Medical Oncology & Cancer Genomics Netherlands, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
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RNA-Based CTC Analysis Provides Prognostic Information in Metastatic Breast Cancer. Diagnostics (Basel) 2021; 11:diagnostics11030513. [PMID: 33799422 PMCID: PMC7998407 DOI: 10.3390/diagnostics11030513] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/08/2021] [Accepted: 03/12/2021] [Indexed: 12/16/2022] Open
Abstract
In metastatic breast cancer (MBC) the molecular characterization of circulating tumor cells (CTCs) provides a unique tool to understand metastasis-biology and therapy-resistance. We evaluated the prognostic significance of gene expression in EpCAM(+) CTCs in 46 MBC patients based on a long follow-up. We selected a panel consisting of stem cell markers (CD24, CD44, ALDH1), the mesenchymal marker TWIST1, receptors (ESR1, PGR, HER2, EGFR) and the epithelial marker CK-19. Singleplex RT-qPCR was used for TWIST1 and CK-19 and multiplex RT-qPCR for stem cell markers and receptors. A group of 19 healthy donors (HD) was used as control. Univariate (p = 0.001) and multivariate analysis (p = 0.002) revealed the prognostic value of combined gene expression of CK-19(+), CD44high/CD24low, ALDH1high/CD24low and HER2 over-expression for overall survival (OS). The Kaplan–Meier estimates of OS were significantly different in patients positive for CK-19 (p = 0.028), CD44high/CD24low (p = 0.002), ALDH1high/CD24low (p = 0.007) and HER2-positive (p = 0.022). Our results indicate that combined gene expression analysis in EpCAM(+) CTCs provides prognostic information in MBC.
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8
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Fabisiewicz A, Szostakowska-Rodzos M, Zaczek AJ, Grzybowska EA. Circulating Tumor Cells in Early and Advanced Breast Cancer; Biology and Prognostic Value. Int J Mol Sci 2020; 21:E1671. [PMID: 32121386 PMCID: PMC7084781 DOI: 10.3390/ijms21051671] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 12/24/2022] Open
Abstract
Breast cancer metastasis is the leading cause of cancer deaths in women and is difficult to combat due to the long periods in which disseminated cells retain a potential to be re-activated and start the relapse. Assessing the number and molecular profile of circulating tumor cells (CTCs) in breast cancer patients, especially in early breast cancer, should help in identifying the possibility of relapse in time for therapeutic intervention to prevent or delay recurrence. While metastatic breast cancer is considered incurable, molecular analysis of CTCs still have a potential to define particular susceptibilities of the cells representing the current tumor burden, which may differ considerably from the cells of the primary tumor, and offer more tailored therapy to the patients. In this review we inspect the routes to metastasis and how they can be linked to specific features of CTCs, how CTC analysis may be used in therapy, and what is the current status of the research and efforts to include CTC analysis in clinical practice.
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Affiliation(s)
- Anna Fabisiewicz
- Department of Molecular and Translational Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Roentgena 5, 02-781 Warsaw, Poland; (A.F.); (M.S.-R.)
| | - Malgorzata Szostakowska-Rodzos
- Department of Molecular and Translational Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Roentgena 5, 02-781 Warsaw, Poland; (A.F.); (M.S.-R.)
| | - Anna J. Zaczek
- Laboratory of Translational Oncology, Intercollegiate Faculty of Biotechnology, Medical University of Gdańsk, Gdańsk, Debinki 1, 80-211 Gdansk, Poland;
| | - Ewa A. Grzybowska
- Department of Molecular and Translational Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Roentgena 5, 02-781 Warsaw, Poland; (A.F.); (M.S.-R.)
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Epithelial-Mesenchymal Plasticity in Circulating Tumor Cells, the Precursors of Metastasis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1220:11-34. [PMID: 32304077 DOI: 10.1007/978-3-030-35805-1_2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Circulating tumor cells offer an unprecedented window into the metastatic cascade, and to some extent can be considered as intermediates in the process of metastasis. They exhibit dynamic oscillations in epithelial to mesenchymal plasticity and provide important opportunities for prognosis, therapy response monitoring, and targeting of metastatic disease. In this manuscript, we review the involvement of epithelial-mesenchymal plasticity in the early steps of metastasis and what we have learned about its contribution to genomic instability and genetic diversity, tumor progression and therapeutic responses using cell culture, mouse models and circulating tumor cells enriched from patients.
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10
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Abdulmawjood B, Roma-Rodrigues C, Fernandes AR, Baptista PV. Liquid biopsies in myeloid malignancies. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2019; 2:1044-1061. [PMID: 35582281 PMCID: PMC9019201 DOI: 10.20517/cdr.2019.88] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/06/2019] [Accepted: 12/10/2019] [Indexed: 12/12/2022]
Abstract
Hematologic malignancies are the most common type of cancer affecting children and young adults, and encompass diseases, such as leukemia, lymphoma, and myeloma, all of which impact blood associated tissues such as the bone marrow, lymphatic system, and blood cells. Clinical diagnostics of these malignancies relies heavily on the use of bone marrow samples, which is painful, debilitating, and not free from risks for leukemia patients. Liquid biopsies are based on minimally invasive assessment of markers in the blood (and other fluids) and have the potential to improve the efficacy of diagnostic/therapeutic strategies in leukemia patients, providing a useful tool for the real time molecular profiling of patients. The most promising noninvasive biomarkers are circulating tumor cells, circulating tumor DNA, microRNAs, and exosomes. Herein, we discuss the role of assessing these circulating biomarkers for the understanding of tumor progression and metastasis, tumor progression dynamics through treatment and for follow-up.
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Affiliation(s)
- Bilal Abdulmawjood
- UCIBIO, Department of Life Sciences, Faculdade de Ciências e Tecnologia, Universidade NOVA de Lisboa, Campus Caparica, Caparica 2829-516, Portugal
| | - Catarina Roma-Rodrigues
- UCIBIO, Department of Life Sciences, Faculdade de Ciências e Tecnologia, Universidade NOVA de Lisboa, Campus Caparica, Caparica 2829-516, Portugal
| | - Alexandra R Fernandes
- UCIBIO, Department of Life Sciences, Faculdade de Ciências e Tecnologia, Universidade NOVA de Lisboa, Campus Caparica, Caparica 2829-516, Portugal
| | - Pedro V Baptista
- UCIBIO, Department of Life Sciences, Faculdade de Ciências e Tecnologia, Universidade NOVA de Lisboa, Campus Caparica, Caparica 2829-516, Portugal
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11
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Lianidou E, Pantel K. Liquid biopsies. Genes Chromosomes Cancer 2019; 58:219-232. [PMID: 30382599 DOI: 10.1002/gcc.22695] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 08/28/2018] [Accepted: 10/01/2018] [Indexed: 02/06/2023] Open
Abstract
Liquid biopsy is based on minimally invasive blood tests and has a high potential to significantly change the therapeutic strategy in cancer patients, providing an extremely powerful and reliable noninvasive clinical tool for the individual molecular profiling of patients in real time. Liquid biopsy approaches include the analysis of circulating tumor cells (CTCs), circulating tumor DNA (ctDNA), circulating miRNAs, and tumor-derived extracellular vesicles (EVs) that are shed from primary tumors and their metastatic sites into peripheral blood. The major advantage of liquid biopsy analysis is that it is minimally invasive, and can be serially repeated, thus allowing extracting information from the tumor in real time. Moreover, the identification of predictive biomarkers in peripheral blood that can monitor response to therapy in real time holds a very strong potential for novel approaches in the therapeutic management of cancer patients. In this review, we summarize recent knowledge on CTCs and ctDNA and discuss future trends in the field.
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Affiliation(s)
- Evi Lianidou
- Analysis of Circulating Tumor Cells Laboratory, Department of Chemistry, University of Athens, Athens, Greece
| | - Klaus Pantel
- Department of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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12
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de Kruijff IE, Sieuwerts AM, Onstenk W, Jager A, Hamberg P, de Jongh FE, Smid M, Kraan J, Timmermans MA, Martens JWM, Sleijfer S. Androgen receptor expression in circulating tumor cells of patients with metastatic breast cancer. Int J Cancer 2019; 145:1083-1089. [PMID: 30761532 DOI: 10.1002/ijc.32209] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/28/2018] [Accepted: 01/28/2019] [Indexed: 12/13/2022]
Abstract
The androgen receptor (AR) has potential clinical relevance in metastatic breast cancer (mBC) since it might be a treatment target and has been associated with endocrine resistance. A minimal-invasive way to determine AR expression on metastatic tumor cells is by characterization of circulating tumor cells (CTCs). Here, we assessed AR mRNA expression in CTCs (CTC-AR) and in matched primary tumor samples from mBC patients representing different breast cancer subtypes. In addition, we explored CTC-AR-status in relation to outcome on endocrine therapy. AR, and 92 AR or estrogen receptor (ER) related genes, were measured in CellSearch-enriched CTCs from 124 mBC patients and in 52 matched FFPE primary tissues using quantitative reverse-transcriptase PCR. AR in CTCs was considered positive if the expression was 1 standard deviation higher than the expression measured in 11 healthy blood donors. A total of 31% of the mBC patients had AR-positive (AR+) CTCs. 58% of the matched CTC and primary tumor samples were discordant with respect to AR status, observing both switches from AR+ to AR-negative (AR-) and vice versa. There was no statistically significant difference in progression-free survival for patients treated with ER-targeting drugs and CTC-AR-status (13 AR+/ 37 AR- cases, p = 0.28). Thus, AR can be determined in RNA isolated from CTCs, with in our set 31% AR-positive samples. Given the discordance between AR status in CTC samples and corresponding primary tumors, determination of AR expression in CTCs might be a promising tool to select mBC patients for AR inhibiting agents.
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Affiliation(s)
- Ingeborg E de Kruijff
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Anieta M Sieuwerts
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Wendy Onstenk
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Paul Hamberg
- Department of Medical Oncology, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Felix E de Jongh
- Department of Medical Oncology, Ikazia Ziekenhuis, Rotterdam, The Netherlands
| | - Marcel Smid
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jaco Kraan
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Mieke A Timmermans
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - John W M Martens
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Stefan Sleijfer
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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13
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Keup C, Storbeck M, Hauch S, Hahn P, Sprenger-Haussels M, Tewes M, Mach P, Hoffmann O, Kimmig R, Kasimir-Bauer S. Cell-Free DNA Variant Sequencing Using CTC-Depleted Blood for Comprehensive Liquid Biopsy Testing in Metastatic Breast Cancer. Cancers (Basel) 2019; 11:E238. [PMID: 30781720 PMCID: PMC6406821 DOI: 10.3390/cancers11020238] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 02/08/2019] [Accepted: 02/12/2019] [Indexed: 12/17/2022] Open
Abstract
Liquid biopsy analytes such as cell-free DNA (cfDNA) and circulating tumor cells (CTCs) exhibit great potential for personalized treatment. Since cfDNA and CTCs are considered to give additive information and blood specimens are limited, isolation of cfDNA and CTC in an "all from one tube" format is desired. We investigated whether cfDNA variant sequencing from CTC-depleted blood (CTC-depl. B; obtained after positive immunomagnetic isolation of CTCs (AdnaTest EMT-2/Stem Cell Select, QIAGEN)) impacts the results compared to cfDNA variant sequencing from matched whole blood (WB). Cell-free DNA was isolated using matched WB and CTC-depl. B from 17 hormone receptor positive/human epidermal growth factor receptor 2 negative (HR+/HER2-) metastatic breast cancer patients (QIAamp MinElute ccfDNA Kit, QIAGEN). Cell-free DNA libraries were constructed (customized QIAseq Targeted DNA Panel for Illumina, QIAGEN) with integrated unique molecular indices. Sequencing (on the NextSeq 550 platform, Illumina) and data analysis (Ingenuity Variant Analysis) were performed. RNA expression in CTCs was analyzed by multimarker quantitative PCR. Cell-free DNA concentration and size distribution in the matched plasma samples were not significantly different. Seventy percent of all variants were identical in matched WB and CTC-depl. B, but 115/125 variants were exclusively found in WB/CTC-depl. B. The number of detected variants per patient and the number of exclusively detected variants per patient in only one cfDNA source did not differ between the two matched cfDNA sources. Even the characteristics of the exclusively detected cfDNA variants in either WB or CTC-depl. B were comparable. Thus, cfDNA variants from matched WB and CTC-depl. B exhibited no relevant differences, and parallel isolation of cfDNA and CTCs from only 10 mL of blood in an "all from one tube" format was feasible. Matched cfDNA mutational and CTC transcriptional analyses might empower a comprehensive liquid biopsy analysis to enhance the identification of actionable targets for individual therapy strategies.
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Affiliation(s)
- Corinna Keup
- Department of Gynecology and Obstetrics, University Hospital of Essen, 45122 Essen, Germany.
| | | | | | | | | | - Mitra Tewes
- Department of Medical Oncology, University Hospital of Essen, 45122 Essen, Germany.
| | - Pawel Mach
- Department of Gynecology and Obstetrics, University Hospital of Essen, 45122 Essen, Germany.
| | - Oliver Hoffmann
- Department of Gynecology and Obstetrics, University Hospital of Essen, 45122 Essen, Germany.
| | - Rainer Kimmig
- Department of Gynecology and Obstetrics, University Hospital of Essen, 45122 Essen, Germany.
| | - Sabine Kasimir-Bauer
- Department of Gynecology and Obstetrics, University Hospital of Essen, 45122 Essen, Germany.
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14
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Ruffalo M, Thomas R, Chen J, Lee AV, Oesterreich S, Bar-Joseph Z. Network-guided prediction of aromatase inhibitor response in breast cancer. PLoS Comput Biol 2019; 15:e1006730. [PMID: 30742607 PMCID: PMC6386390 DOI: 10.1371/journal.pcbi.1006730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 02/22/2019] [Accepted: 12/19/2018] [Indexed: 01/07/2023] Open
Abstract
Prediction of response to specific cancer treatments is complicated by significant heterogeneity between tumors in terms of mutational profiles, gene expression, and clinical measures. Here we focus on the response of Estrogen Receptor (ER)+ post-menopausal breast cancer tumors to aromatase inhibitors (AI). We use a network smoothing algorithm to learn novel features that integrate several types of high throughput data and new cell line experiments. These features greatly improve the ability to predict response to AI when compared to prior methods. For a subset of the patients, for which we obtained more detailed clinical information, we can further predict response to a specific AI drug. Breast cancer is the second most common type of cancer in women, with an incidence rate of over 250,000 cases per year, and breast cancer cases show significant heterogeneity in clinical and omic measures. Estrogen receptor positive (ER+) tumors typically grow in response to estrogen, and in post menopausal women, estrogen is only produced in peripheral tissues via the aromatase enzyme. Inhibition of aromatase is often an effective treatment for ER+ tumors, but aromatase inhibitor therapy is not effective for all tumors, and causes of this heterogeneity in response are largely not known. In this work, we present a feature construction and classification method to predict response to aromatase inhibitor therapy. We use network smoothing techniques to combine tumor omic data into predictive features, which we use as input to standard machine learning algorithms. We train predictive models using clinical data, including high-quality clinical data from UPMC patients, and show that our method outperforms previous approaches in predicting response to aromatase inhibitor therapy.
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Affiliation(s)
- Matthew Ruffalo
- Computational Biology Department, School of Computer Science, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | - Roby Thomas
- Women’s Cancer Research Center, Department of Pharmacology and Chemical Biology, UPMC Hillman Cancer Center, Magee Womens Research Institute, Pittsburgh, Pennsylvania, United States of America
| | - Jian Chen
- Women’s Cancer Research Center, Department of Pharmacology and Chemical Biology, UPMC Hillman Cancer Center, Magee Womens Research Institute, Pittsburgh, Pennsylvania, United States of America
| | - Adrian V. Lee
- Women’s Cancer Research Center, Department of Pharmacology and Chemical Biology, UPMC Hillman Cancer Center, Magee Womens Research Institute, Pittsburgh, Pennsylvania, United States of America
| | - Steffi Oesterreich
- Women’s Cancer Research Center, Department of Pharmacology and Chemical Biology, UPMC Hillman Cancer Center, Magee Womens Research Institute, Pittsburgh, Pennsylvania, United States of America
| | - Ziv Bar-Joseph
- Computational Biology Department, School of Computer Science, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
- Machine Learning Department, School of Computer Science, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
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15
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Vitale SR, Sieuwerts AM, Beije N, Kraan J, Angus L, Mostert B, Reijm EA, Van NM, van Marion R, Dirix LY, Hamberg P, de Jongh FE, Jager A, Foekens JA, Vigneri P, Sleijfer S, Jansen MPHM, Martens JWM. An Optimized Workflow to Evaluate Estrogen Receptor Gene Mutations in Small Amounts of Cell-Free DNA. J Mol Diagn 2018; 21:123-137. [PMID: 30296589 DOI: 10.1016/j.jmoldx.2018.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/02/2018] [Accepted: 08/16/2018] [Indexed: 12/24/2022] Open
Abstract
The detection of mutated genes in cell-free DNA (cfDNA) in plasma has emerged as an important minimally invasive way to obtain detailed information regarding tumor biology. Reliable determination of circulating tumor-derived DNA, often present at a low quantity amidst an excess of normal DNA in plasma, would be of added value for screening and monitoring of cancer patients and for hypothesis-generating studies in valuable retrospective cohorts. Our aim was to establish a workflow to simultaneously assess four hotspot estrogen receptor mutations (mESR1) in cfDNA isolated from only 200 μL of plasma by means of uniplex or multiplex pre-amplification combined with digital PCR. This workflow was then applied in metastatic breast cancer (MBC) patients receiving systemic therapies for MBC. In accordance with previous studies, estrogen receptor mutations were more frequently detected in endocrine-treated MBC patients at progressive disease [34.1% (15/44)] than before the start of endocrine therapy [3.9% (2/51); P = 0.001]. For a subset of samples, results were compared with analysis of these mutations by Oncomine-targeted next-generation sequencing, which, although requiring a higher cfDNA input, yielded concordant results. The data establish development and validation of a digital PCR workflow for the simultaneous detection of several tumor-derived mutations in minute amounts of cfDNA and show the potential of this workflow for use on archived volume-limited blood samples.
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Affiliation(s)
- Silvia R Vitale
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands; Cancer Genomics Netherlands, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands; Department of Clinical and Experimental Medicine-Center for Experimental Oncology and Hematology, University of Catania, Catania, Italy
| | - Anieta M Sieuwerts
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands; Cancer Genomics Netherlands, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands.
| | - Nick Beije
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands; Cancer Genomics Netherlands, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Jaco Kraan
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands; Cancer Genomics Netherlands, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Lindsay Angus
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands; Cancer Genomics Netherlands, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Bianca Mostert
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands; Cancer Genomics Netherlands, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Esther A Reijm
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands; Cancer Genomics Netherlands, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Ngoc M Van
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands; Cancer Genomics Netherlands, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Ronald van Marion
- Department of Pathology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Luc Y Dirix
- Translational Cancer Research Unit, Department of Medical Oncology, Oncology Center Gasthuis Zusters Antwerp Hospital Sint Augustinus, Antwerp, Belgium
| | - Paul Hamberg
- Department of Internal Medicine, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands
| | - Felix E de Jongh
- Department of Internal Medicine, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands; Department of Internal Medicine, Ikazia Hospital, Rotterdam, the Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands; Cancer Genomics Netherlands, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - John A Foekens
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands; Cancer Genomics Netherlands, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Paolo Vigneri
- Department of Clinical and Experimental Medicine-Center for Experimental Oncology and Hematology, University of Catania, Catania, Italy
| | - Stefan Sleijfer
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands; Cancer Genomics Netherlands, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Maurice P H M Jansen
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands; Cancer Genomics Netherlands, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - John W M Martens
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands; Cancer Genomics Netherlands, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
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16
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Keup C, Mach P, Aktas B, Tewes M, Kolberg HC, Hauch S, Sprenger-Haussels M, Kimmig R, Kasimir-Bauer S. RNA Profiles of Circulating Tumor Cells and Extracellular Vesicles for Therapy Stratification of Metastatic Breast Cancer Patients. Clin Chem 2018; 64:1054-1062. [DOI: 10.1373/clinchem.2017.283531] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 04/27/2018] [Indexed: 12/16/2022]
Abstract
Abstract
BACKGROUND
Liquid biopsies are discussed to provide surrogate markers for therapy stratification and monitoring. We compared messenger RNA (mRNA) profiles of circulating tumor cells (CTCs) and extracellular vesicles (EVs) in patients with metastatic breast cancer (MBC) to estimate their utility in therapy management.
METHODS
Blood was collected from 35 hormone receptor-positive/HER2-negative patients with MBC at the time of disease progression and at 2 consecutive staging time points. CTCs were isolated from 5 mL of blood by positive immunomagnetic selection, and EVs from 4 mL of plasma by a membrane affinity-based procedure. mRNA was reverse transcribed, preamplified, and analyzed for 18 genes by multimarker quantitative polymerase chain reaction (qPCR) assays. RNA profiles were normalized to healthy donor controls (n = 20), and results were correlated with therapy outcome.
RESULTS
There were great differences in mRNA profiles of EVs and CTCs, with only 5% (21/403) of positive signals identical in both fractions. Transcripts involved in the PI3K signaling pathway were frequently overexpressed in CTCs, and AURKA, PARP1, and SRC signals appeared more often in EVs. Of all patients, 40% and 34% showed ERBB2 and ERBB3 signals, respectively, in CTCs, which was significantly associated with disease progression (P = 0.007). Whereas MTOR signals in CTCs significantly correlated with response (P = 0.046), signals in EVs indicated therapy failure (P = 0.011). The presence of AURKA signals in EVs seemed to be a marker for the indication of unsuccessful treatment of bone metastasis.
CONCLUSIONS
These results emphasize the potential of CTCs and EVs for therapy monitoring and the need for critical evaluation of the implementation of any liquid biopsy in clinical practice.
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Affiliation(s)
- Corinna Keup
- Department of Gynecology and Obstetrics, University Hospital of Essen, Germany
| | - Pawel Mach
- Department of Gynecology and Obstetrics, University Hospital of Essen, Germany
| | - Bahriye Aktas
- Department of Gynecology and Obstetrics, University Hospital of Essen, Germany
- Department of Gynecology, University Hospital of Leipzig, Germany
| | - Mitra Tewes
- Department of Internal Medicine (Cancer Research), University Hospital of Essen, Germany
| | | | | | | | - Rainer Kimmig
- Department of Gynecology and Obstetrics, University Hospital of Essen, Germany
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17
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Hwang WL, Pleskow HM, Miyamoto DT. Molecular analysis of circulating tumors cells: Biomarkers beyond enumeration. Adv Drug Deliv Rev 2018; 125:122-131. [PMID: 29326053 DOI: 10.1016/j.addr.2018.01.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 10/15/2017] [Accepted: 01/05/2018] [Indexed: 12/13/2022]
Abstract
Advances in our molecular understanding of cancer biology have paved the way to an expanding compendium of molecularly-targeted therapies, accompanied by the urgent need for biomarkers that enable the precise selection of the most appropriate therapies for individual cancer patients. Circulating biomarkers such as circulating tumor cells (CTCs) are poised to fill this need, since they are "liquid biopsies" that can be performed non-invasively and serially, and may capture the spectrum of spatial and temporal tumor heterogeneity better than conventional tissue biopsies. Increasing evidence suggests that moving beyond the enumeration of CTCs towards more sophisticated molecular analyses can provide actionable data that may predict and potentially improve clinical outcomes. In this review, we discuss the potential of molecular CTC analyses to serve as prognostic and predictive biomarkers to guide cancer therapy and early cancer detection. As technologies to capture and analyze CTCs continue to increase in sophistication, we anticipate that the potential clinical applications of CTCs will grow exponentially in the coming years.
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Affiliation(s)
- William L Hwang
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States; Massachusetts General Hospital Cancer Center, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Haley M Pleskow
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - David T Miyamoto
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States; Massachusetts General Hospital Cancer Center, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
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18
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Beije N, Sieuwerts AM, Kraan J, Van NM, Onstenk W, Vitale SR, van der Vlugt-Daane M, Dirix LY, Brouwer A, Hamberg P, de Jongh FE, Jager A, Seynaeve CM, Jansen MPHM, Foekens JA, Martens JWM, Sleijfer S. Estrogen receptor mutations and splice variants determined in liquid biopsies from metastatic breast cancer patients. Mol Oncol 2017; 12:48-57. [PMID: 29063679 PMCID: PMC5748489 DOI: 10.1002/1878-0261.12147] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/24/2017] [Accepted: 10/07/2017] [Indexed: 01/09/2023] Open
Abstract
Mutations and splice variants in the estrogen receptor (ER) gene, ESR1, may yield endocrine resistance in metastatic breast cancer (MBC) patients. These putative endocrine resistance markers are likely to emerge during treatment, and therefore, its detection in liquid biopsies, such as circulating tumor cells (CTCs) and cell‐free DNA (cfDNA), is of great interest. This research aimed to determine whether ESR1 mutations and splice variants occur more frequently in CTCs of MBC patients progressing on endocrine treatment. In addition, the presence of ESR1 mutations was evaluated in matched cfDNA and compared to CTCs. CellSearch‐enriched CTC fractions (≥5/7.5 mL) of two MBC cohorts were evaluated, namely (a) patients starting first‐line endocrine therapy (n = 43, baseline cohort) and (b) patients progressing on any line of endocrine therapy (n = 40, progressing cohort). ESR1 hotspot mutations (D538G and Y537S/N/C) were evaluated in CTC‐enriched DNA using digital PCR and compared with matched cfDNA (n = 18 baseline cohort; n = 26 progressing cohort). Expression of ESR1 full‐length and 4 of its splice variants (∆5, ∆7, 36 kDa, and 46 kDa) was evaluated in CTC‐enriched mRNA. It was observed that in the CTCs, the ESR1 mutations were not enriched in the progressing cohort (8%), when compared with the baseline cohort (5%) (P = 0.66). In the cfDNA, however, ESR1 mutations were more prevalent in the progressing cohort (42%) than in the baseline cohort (11%) (P = 0.04). Three of the same mutations were observed in both CTCs and cfDNA, 1 mutation in CTCs only, and 11 in cfDNA only. Only the ∆5 ESR1 splice variant was CTC‐specific expressed, but was not enriched in the progressing cohort. In conclusion, sensitivity for detecting ESR1 mutations in CTC‐enriched fractions was lower than for cfDNA. ESR1 mutations detected in cfDNA, rarely present at the start of first‐line endocrine therapy, were enriched at progression, strongly suggesting a role in conferring endocrine resistance in MBC.
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Affiliation(s)
- Nick Beije
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anieta M Sieuwerts
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jaco Kraan
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ngoc M Van
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Wendy Onstenk
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Silvia R Vitale
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Clinical and Molecular Medicine, University of Catania, Italy
| | - Michelle van der Vlugt-Daane
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Luc Y Dirix
- Translational Cancer Research Unit, Department of Medical Oncology, Oncology Center GZA Hospital Sint Augustinus, Antwerp, Belgium
| | - Anja Brouwer
- Translational Cancer Research Unit, Department of Medical Oncology, Oncology Center GZA Hospital Sint Augustinus, Antwerp, Belgium
| | - Paul Hamberg
- Department of Internal Medicine, Franciscus Gasthuis, Rotterdam, The Netherlands
| | - Felix E de Jongh
- Department of Internal Medicine, Ikazia Hospital, Rotterdam, The Netherlands
| | - Agnes Jager
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Caroline M Seynaeve
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Maurice P H M Jansen
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - John A Foekens
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - John W M Martens
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Stefan Sleijfer
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
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19
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Beije N, Sieuwerts AM, Kraan J, Van NM, Onstenk W, Vitale SR, van der Vlugt-Daane M, Dirix LY, Brouwer A, Hamberg P, de Jongh FE, Jager A, Seynaeve CM, Jansen MPHM, Foekens JA, Martens JWM, Sleijfer S. Estrogen receptor mutations and splice variants determined in liquid biopsies from metastatic breast cancer patients. Mol Oncol 2017. [PMID: 29063679 DOI: 10.1002/1878‐0261.12147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Mutations and splice variants in the estrogen receptor (ER) gene, ESR1, may yield endocrine resistance in metastatic breast cancer (MBC) patients. These putative endocrine resistance markers are likely to emerge during treatment, and therefore, its detection in liquid biopsies, such as circulating tumor cells (CTCs) and cell-free DNA (cfDNA), is of great interest. This research aimed to determine whether ESR1 mutations and splice variants occur more frequently in CTCs of MBC patients progressing on endocrine treatment. In addition, the presence of ESR1 mutations was evaluated in matched cfDNA and compared to CTCs. CellSearch-enriched CTC fractions (≥5/7.5 mL) of two MBC cohorts were evaluated, namely (a) patients starting first-line endocrine therapy (n = 43, baseline cohort) and (b) patients progressing on any line of endocrine therapy (n = 40, progressing cohort). ESR1 hotspot mutations (D538G and Y537S/N/C) were evaluated in CTC-enriched DNA using digital PCR and compared with matched cfDNA (n = 18 baseline cohort; n = 26 progressing cohort). Expression of ESR1 full-length and 4 of its splice variants (∆5, ∆7, 36 kDa, and 46 kDa) was evaluated in CTC-enriched mRNA. It was observed that in the CTCs, the ESR1 mutations were not enriched in the progressing cohort (8%), when compared with the baseline cohort (5%) (P = 0.66). In the cfDNA, however, ESR1 mutations were more prevalent in the progressing cohort (42%) than in the baseline cohort (11%) (P = 0.04). Three of the same mutations were observed in both CTCs and cfDNA, 1 mutation in CTCs only, and 11 in cfDNA only. Only the ∆5 ESR1 splice variant was CTC-specific expressed, but was not enriched in the progressing cohort. In conclusion, sensitivity for detecting ESR1 mutations in CTC-enriched fractions was lower than for cfDNA. ESR1 mutations detected in cfDNA, rarely present at the start of first-line endocrine therapy, were enriched at progression, strongly suggesting a role in conferring endocrine resistance in MBC.
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Affiliation(s)
- Nick Beije
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anieta M Sieuwerts
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jaco Kraan
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ngoc M Van
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Wendy Onstenk
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Silvia R Vitale
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Clinical and Molecular Medicine, University of Catania, Italy
| | - Michelle van der Vlugt-Daane
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Luc Y Dirix
- Translational Cancer Research Unit, Department of Medical Oncology, Oncology Center GZA Hospital Sint Augustinus, Antwerp, Belgium
| | - Anja Brouwer
- Translational Cancer Research Unit, Department of Medical Oncology, Oncology Center GZA Hospital Sint Augustinus, Antwerp, Belgium
| | - Paul Hamberg
- Department of Internal Medicine, Franciscus Gasthuis, Rotterdam, The Netherlands
| | - Felix E de Jongh
- Department of Internal Medicine, Ikazia Hospital, Rotterdam, The Netherlands
| | - Agnes Jager
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Caroline M Seynaeve
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Maurice P H M Jansen
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - John A Foekens
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - John W M Martens
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Stefan Sleijfer
- Erasmus MC Cancer Institute, Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus University Medical Center, Rotterdam, The Netherlands
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20
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Xie Z, Gao X, Cheng K, Yu L. Correlation between the presence of circulating tumor cells and the pathologic type and staging of non-small cell lung cancer during the early postoperative period. Oncol Lett 2017; 14:5825-5830. [PMID: 29113213 PMCID: PMC5661428 DOI: 10.3892/ol.2017.6910] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 07/13/2017] [Indexed: 01/04/2023] Open
Abstract
This study investigated possible correlations between the presence of circulating tumor cells (CTCs) and the pathologic types and staging of non-small cell lung cancer (NSCLC) during the early postoperative period. Sixty-nine patients with NSCLC were enrolled in the study. Clinical staging was performed by postoperative pathological examination and imaging. Multiple mRNA in situ analyses targeting specifically expressed genes were carried out to identify the presence of CTCs. Correlations between age, sex, TNM stage and pathological types with the detection rate of CTCs were also established. The results showed the positivity rate of CTCs in patients >55 years was significantly higher than that of patients <55 years (94.74 vs. 70.97%, P<0.05). There was no significant difference in the positivity rate of CTCs between male and female patients (85.71 vs. 85.29%, P>0.05). The correlations between the detection rate of epithelial type or mixed type CTCs with tumor size, lymph node metastasis and distant metastasis TNM in patients with NSCLC were not significant (P>0.05). However, higher TNM stages correlated with higher detection rates of mesenchymal CTCs (P<0.05). There were also significant differences in the detection rates of CTCs amongst the three different pathologic types (adenocarcinoma, squamous cell and large cell carcinomas) (P<0.05). Based on our results, the detection of mesenchymal CTCs during the early postoperative period can help prognosticate the recurrence and metastasis of NSCLC, which is beneficial to the development of individualized treatment strategies.
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Affiliation(s)
- Zhanqiang Xie
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong 524001, P.R. China
| | - Xiaotian Gao
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong 524001, P.R. China
| | - Keluo Cheng
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong 524001, P.R. China
| | - Lishuang Yu
- Department of Gastroenterology, The Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong 524001, P.R. China
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21
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Hwang WL, Hwang KL, Miyamoto DT. The promise of circulating tumor cells for precision cancer therapy. Biomark Med 2016; 10:1269-1285. [PMID: 27924634 PMCID: PMC5827810 DOI: 10.2217/bmm-2016-0192] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 09/27/2016] [Indexed: 12/20/2022] Open
Abstract
The rapidly growing array of therapeutic options in cancer requires informative biomarkers to guide the rational selection and precision application of appropriate therapies. Circulating biomarkers such as circulating tumor cells have immense potential as noninvasive, serial 'liquid biopsies' that may be more representative of the complete spectrum of a patient's individual malignancy than spatially and temporally restricted tumor biopsies. In this review, we discuss the current state-of-the-art in the isolation and molecular characterization of circulating tumor cells as well as their utility in a wide range of clinical applications such as prognostics, treatment monitoring and identification of novel therapeutic targets and resistance mechanisms to enable real-time adjustments in the clinical management of cancer.
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Affiliation(s)
- William L Hwang
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
- Massachusetts General Hospital Cancer Center, Boston, MA 02114, USA
| | - Katie L Hwang
- Massachusetts General Hospital Cancer Center, Boston, MA 02114, USA
- Medical Scientist Training Program, Harvard Medical School, Boston, MA 02115, USA
| | - David T Miyamoto
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
- Massachusetts General Hospital Cancer Center, Boston, MA 02114, USA
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22
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Beije N, Onstenk W, Kraan J, Sieuwerts AM, Hamberg P, Dirix LY, Brouwer A, de Jongh FE, Jager A, Seynaeve CM, Van NM, Foekens JA, Martens JWM, Sleijfer S. Prognostic Impact of HER2 and ER Status of Circulating Tumor Cells in Metastatic Breast Cancer Patients with a HER2-Negative Primary Tumor. Neoplasia 2016; 18:647-653. [PMID: 27764697 PMCID: PMC5071539 DOI: 10.1016/j.neo.2016.08.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 08/24/2016] [Accepted: 08/29/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Preclinical and clinical studies have reported that human epidermal growth factor receptor 2 (HER2) overexpression yields resistance to endocrine therapies. Here the prevalence and prognostic impact of HER2-positive circulating tumor cells (CTCs) were investigated retrospectively in metastatic breast cancer (MBC) patients with a HER2-negative primary tumor receiving endocrine therapy. Additionally, the prevalence and prognostic significance of HER2-positive CTCs were explored in a chemotherapy cohort, as well as the prognostic impact of the estrogen receptor (ER) CTC status in both cohorts. METHODS Included were MBC patients with a HER2-negative primary tumor, with ≥1 detectable CTC, starting a new line of treatment. CTCs were enumerated using the CellSearch system, characterized for HER2 with the CellSearch anti-HER2 phenotyping reagent, and characterized for ER mRNA expression. Primary end point was progression-free rate after 6 months (PFR6months) of endocrine treatment in HER2-positive versus HER2-negative CTC patients. RESULTS HER2-positive CTCs were present in 29% of all patients. In the endocrine cohort (n=72), the PFR6months was 53% for HER2-positive versus 68% for HER2-negative CTC patients (P=.23). In the chemotherapy cohort (n=82), no prognostic value of HER2-positive CTCs on PFR6months was observed either. Discordances in ER status between the primary tumor and CTCs occurred in 25% of all patients but had no prognostic value in exploratory survival analyses. CONCLUSION Discordances regarding HER2 status and ER status between CTCs and the primary tumor occurred frequently but had no prognostic impact in our MBC patient cohorts.
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Affiliation(s)
- Nick Beije
- Erasmus MC Cancer Institute, Erasmus University Medical Center, Department of Medical Oncology and Cancer Genomics Netherlands, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands.
| | - Wendy Onstenk
- Erasmus MC Cancer Institute, Erasmus University Medical Center, Department of Medical Oncology and Cancer Genomics Netherlands, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Jaco Kraan
- Erasmus MC Cancer Institute, Erasmus University Medical Center, Department of Medical Oncology and Cancer Genomics Netherlands, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Anieta M Sieuwerts
- Erasmus MC Cancer Institute, Erasmus University Medical Center, Department of Medical Oncology and Cancer Genomics Netherlands, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Paul Hamberg
- Franciscus Gasthuis, Department of Internal Medicine, Kleiweg 500, 3045 PM, Rotterdam, The Netherlands
| | - Luc Y Dirix
- Oncology Center GZA Hospitals Sint Augustinus, Translational Cancer Research Unit, Department of Medical Oncology, Oosterveldlaan 26, 2610, Antwerp, Belgium
| | - Anja Brouwer
- Oncology Center GZA Hospitals Sint Augustinus, Translational Cancer Research Unit, Department of Medical Oncology, Oosterveldlaan 26, 2610, Antwerp, Belgium
| | - Felix E de Jongh
- Ikazia Hospital, Department of Internal Medicine, Montessoriweg 1, 3083 AN, Rotterdam, The Netherlands
| | - Agnes Jager
- Erasmus MC Cancer Institute, Erasmus University Medical Center, Department of Medical Oncology and Cancer Genomics Netherlands, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Caroline M Seynaeve
- Erasmus MC Cancer Institute, Erasmus University Medical Center, Department of Medical Oncology and Cancer Genomics Netherlands, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Ngoc M Van
- Erasmus MC Cancer Institute, Erasmus University Medical Center, Department of Medical Oncology and Cancer Genomics Netherlands, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - John A Foekens
- Erasmus MC Cancer Institute, Erasmus University Medical Center, Department of Medical Oncology and Cancer Genomics Netherlands, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - John W M Martens
- Erasmus MC Cancer Institute, Erasmus University Medical Center, Department of Medical Oncology and Cancer Genomics Netherlands, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Stefan Sleijfer
- Erasmus MC Cancer Institute, Erasmus University Medical Center, Department of Medical Oncology and Cancer Genomics Netherlands, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
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