1
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Lynce F, Mainor C, Donahue RN, Geng X, Jones G, Schlam I, Wang H, Toney NJ, Jochems C, Schlom J, Zeck J, Gallagher C, Nanda R, Graham D, Stringer-Reasor EM, Denduluri N, Collins J, Chitalia A, Tiwari S, Nunes R, Kaltman R, Khoury K, Gatti-Mays M, Tarantino P, Tolaney SM, Swain SM, Pohlmann P, Parsons HA, Isaacs C. Adjuvant nivolumab, capecitabine or the combination in patients with residual triple-negative breast cancer: the OXEL randomized phase II study. Nat Commun 2024; 15:2691. [PMID: 38538574 PMCID: PMC10973408 DOI: 10.1038/s41467-024-46961-x] [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: 01/05/2023] [Accepted: 03/15/2024] [Indexed: 04/04/2024] Open
Abstract
Chemotherapy and immune checkpoint inhibitors have a role in the post-neoadjuvant setting in patients with triple-negative breast cancer (TNBC). However, the effects of nivolumab, a checkpoint inhibitor, capecitabine, or the combination in changing peripheral immunoscore (PIS) remains unclear. This open-label randomized phase II OXEL study (NCT03487666) aimed to assess the immunologic effects of nivolumab, capecitabine, or the combination in terms of the change in PIS (primary endpoint). Secondary endpoints included the presence of ctDNA, toxicity, clinical outcomes at 2-years and association of ctDNA and PIS with clinical outcomes. Forty-five women with TNBC and residual invasive disease after standard neoadjuvant chemotherapy were randomized to nivolumab, capecitabine, or the combination. Here we show that a combination of nivolumab plus capecitabine leads to a greater increase in PIS from baseline to week 6 (91%) compared with nivolumab (47%) or capecitabine (53%) alone (log-rank p = 0.08), meeting the pre-specified primary endpoint. In addition, the presence of circulating tumor DNA (ctDNA) is associated with disease recurrence, with no new safety signals in the combination arm. Our results provide efficacy and safety data on this combination in TNBC and support further development of PIS and ctDNA analyses to identify patients at high risk of recurrence.
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Affiliation(s)
- Filipa Lynce
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Candace Mainor
- MedStar Georgetown University Hospital, Washington, DC, USA
| | - Renee N Donahue
- Center for Immuno-Oncology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Xue Geng
- Georgetown University, Washington, DC, USA
| | | | - Ilana Schlam
- MedStar Washington Hospital Center, Washington, DC, USA
- Tufts Medical Center, Boston, MA, USA
| | | | - Nicole J Toney
- Center for Immuno-Oncology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Caroline Jochems
- Center for Immuno-Oncology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey Schlom
- Center for Immuno-Oncology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jay Zeck
- MedStar Georgetown University Hospital, Washington, DC, USA
| | | | | | - Deena Graham
- Hackensack University Medical Center, Hackensack, NJ, USA
| | | | | | - Julie Collins
- MedStar Georgetown University Hospital, Washington, DC, USA
- AstraZeneca, Arlington, VA, USA
| | - Ami Chitalia
- MedStar Washington Hospital Center, Washington, DC, USA
| | - Shruti Tiwari
- MedStar Washington Hospital Center, Washington, DC, USA
| | - Raquel Nunes
- Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, MD, USA
- AstraZeneca, Arlington, VA, USA
| | | | - Katia Khoury
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Paolo Tarantino
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sara M Tolaney
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Paula Pohlmann
- MedStar Georgetown University Hospital, Washington, DC, USA
| | - Heather A Parsons
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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2
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Li JJX, Tse GM. Immunocytochemical markers, molecular testing and digital cytopathology for aspiration cytology of metastatic breast carcinoma. Cytopathology 2024; 35:218-225. [PMID: 37985397 DOI: 10.1111/cyt.13333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/28/2023] [Accepted: 11/02/2023] [Indexed: 11/22/2023]
Abstract
Fine-needle aspiration cytology (FNAC) is a versatile diagnostic procedure uniquely suited for tissue biopsy of breast carcinomas and axillary metastases and/or recurrences. With the expanding treatment options and accompanying theragnostic tests, it is crucial to recognize the developments on ancillary testing and digital cytopathology techniques related to aspiration cytology of metastatic breast carcinoma. In this review, we aim to summarize and update the evidence of immunocytochemistry, for the detection of carcinoma cells (epithelial markers), confirmation of breast primary (breast-specific markers), assessment of surrogate immunostains (hormone receptors, ki-67 proliferative index and HER2) and theragnostic biomarkers, with discussion on potential diagnostic pitfalls, followed by the application of molecular tests, and digital cytopathologic techniques for assessing metastatic breast carcinoma in cytology.
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Affiliation(s)
- Joshua J X Li
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Gary M Tse
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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3
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Song F, Tarantino P, Garrido-Castro A, Lynce F, Tolaney SM, Schlam I. Immunotherapy for Early-Stage Triple Negative Breast Cancer: Is Earlier Better? Curr Oncol Rep 2024; 26:21-33. [PMID: 38198112 DOI: 10.1007/s11912-023-01487-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/11/2024]
Abstract
PURPOSE OF REVIEW In this narrative review, we discuss the optimal timing of immune checkpoint inhibitors (ICI) in early triple negative breast cancer (TNBC), the landscape of predictive biomarkers for the use of immunotherapy, and the mounting literature suggesting a benefit for an early use of ICI. RECENT FINDINGS TNBC is associated with a poor prognosis relative to other breast cancer subtypes, and until recently, the treatment of TNBC was limited to cytotoxic chemotherapy. In 2021, the immune-checkpoint inhibitor, pembrolizumab, was approved in combination with neoadjuvant chemotherapy for patients with high-risk early stage TNBC. This approval changed the treatment paradigm of early TNBC concomitantly raised several challenges in clinical practice, pertaining to patient selection, toxicity management, and post-neoadjuvant treatment, among others. The introduction of neoadjuvant chemoimmunotherapy has transformed the treatment landscape for early TNBC. However, several challenges, including patient selection, toxicity management, and the identification of predictive biomarkers, need to be addressed. Future research should focus on refining the timing and duration of immunotherapy, optimizing the chemotherapy partner, and exploring novel predictive biomarkers of response or toxicity.
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Affiliation(s)
- Fei Song
- Division of Hematology and Oncology, Tufts Medical Center, Boston, MA, USA
| | - Paolo Tarantino
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
| | - Ana Garrido-Castro
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Filipa Lynce
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Ilana Schlam
- Division of Hematology and Oncology, Tufts Medical Center, Boston, MA, USA.
- Tufts University, Boston, MA, USA.
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4
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Heater NK, Somayaji K, Gradishar W. Treatment of residual disease following neoadjuvant therapy in breast cancer. J Surg Oncol 2024; 129:18-25. [PMID: 37990834 DOI: 10.1002/jso.27523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 11/23/2023]
Abstract
Substantial advances have been made in the systemic treatment of breast cancer with residual disease following neoadjuvant therapy. We reviewed recent and ongoing studies informing the standard clinical management of residual disease by subtype: HER2+, TNBC, and HR+/HER2-, as well as strategies for BRCA+ disease. We conclude with a discussion of ongoing clinical trials and current controversies regarding the treatment of residual disease in breast cancer.
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Affiliation(s)
- Natalie K Heater
- Department of Medicine, McGaw Medical Center of Northwestern University, Chicago, Illinois, USA
| | - Khyati Somayaji
- Department of Medicine, McGaw Medical Center of Northwestern University, Chicago, Illinois, USA
| | - William Gradishar
- Department of Medicine, McGaw Medical Center of Northwestern University, Chicago, Illinois, USA
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois, USA
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5
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Lynce F, Mainor C, Donahue RN, Geng X, Jones G, Schlam I, Wang H, Toney NJ, Jochems C, Schlom J, Zeck J, Gallagher C, Nanda R, Graham D, Stringer-Reasor EM, Denduluri N, Collins J, Chitalia A, Tiwari S, Nunes R, Kaltman R, Khoury K, Gatti-Mays M, Tarantino P, Tolaney SM, Swain SM, Pohlmann P, Parsons HA, Isaacs C. Adjuvant nivolumab, capecitabine or the combination in patients with residual triple-negative breast cancer: the OXEL randomized phase II study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.04.23297559. [PMID: 38105958 PMCID: PMC10723519 DOI: 10.1101/2023.12.04.23297559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Chemotherapy and immune checkpoint inhibitors have a role in the post-neoadjuvant setting in patients with triple-negative breast cancer (TNBC). However, the effects of nivolumab, a checkpoint inhibitor, capecitabine, or the combination in changing peripheral immunoscore (PIS) remains unclear. This open-label randomized phase II OXEL study (NCT03487666) aimed to assess the immunologic effects of nivolumab, capecitabine, or the combination in terms of the change in PIS (primary endpoint). Secondary endpoints include the presence of ctDNA, toxicity, clinical outcomes at 2-years and association of ctDNA and PIS with clinical outcomes. Forty-five women with TNBC and residual invasive disease after standard neoadjuvant chemotherapy were randomized to nivolumab, capecitabine, or the combination. Here we show that a combination of nivolumab plus capecitabine leads to a greater increase in PIS from baseline to week 6 (91%) compared with nivolumab (47%) or capecitabine (53%) alone (log-rank p = 0.08), meeting the pre-specified primary endpoint. In addition, the presence of circulating tumor DNA (ctDNA) was associated with disease recurrence, with no new safety signals in the combination arm. Our results provide efficacy and safety data on this combination in TNBC and support further development of PIS and ctDNA analyses to identify patients at high risk of recurrence.
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Affiliation(s)
- Filipa Lynce
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Candace Mainor
- MedStar Georgetown University Hospital, Washington, DC, USA
| | - Renee N. Donahue
- Center for Immuno-Oncology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Xue Geng
- Georgetown University, Washington, DC
| | - Greg Jones
- NeoGenomics, Research Triangle Park, NC, USA
| | - Ilana Schlam
- MedStar Washington Hospital Center, Washington, DC, USA
- Tufts Medical Center, Boston, MA, USA
| | | | - Nicole J. Toney
- Center for Immuno-Oncology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Caroline Jochems
- Center for Immuno-Oncology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey Schlom
- Center for Immuno-Oncology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jay Zeck
- MedStar Georgetown University Hospital, Washington, DC, USA
| | | | | | - Deena Graham
- Hackensack University Medical Center, Hackensack, NJ, USA
| | | | | | - Julie Collins
- MedStar Georgetown University Hospital, Washington, DC, USA
| | - Ami Chitalia
- MedStar Washington Hospital Center, Washington, DC, USA
| | - Shruti Tiwari
- MedStar Washington Hospital Center, Washington, DC, USA
| | - Raquel Nunes
- Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | | | - Katia Khoury
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Paolo Tarantino
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sara M. Tolaney
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Paula Pohlmann
- MedStar Georgetown University Hospital, Washington, DC, USA
| | - Heather A. Parsons
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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6
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Wong RSJ, Ong RJM, Lim JSJ. Immune checkpoint inhibitors in breast cancer: development, mechanisms of resistance and potential management strategies. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2023; 6:768-787. [PMID: 38263984 PMCID: PMC10804393 DOI: 10.20517/cdr.2023.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 10/14/2023] [Accepted: 10/31/2023] [Indexed: 01/25/2024]
Abstract
The use of immune checkpoint inhibitors (ICIs) has increased exponentially in the past decade, although its progress specifically for breast cancer has been modest. The first U.S. Food and Drug Administration approval for ICI in breast cancer came in 2019, eight years after the first-ever approval of an ICI. At present, current indications for ICIs are relevant only to a subset of patients with triple-negative breast cancer, or those displaying high microsatellite instability or deficiency in the mismatch repair protein pathway. With an increasing understanding of the limitations of using ICIs, which stem from breast cancer being innately poorly immunogenic, as well as the presence of various intrinsic and acquired resistance pathways, ongoing trials are evaluating different combination therapies to overcome these barriers. In this review, we aim to describe the development timeline of ICIs and resistance mechanisms limiting their utility, and summarise the available approaches and ongoing trials relevant to overcoming each resistance mechanism.
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Affiliation(s)
- Rachel SJ Wong
- Department of Haematology-Oncology, National University Cancer Institute, National University Hospital, Singapore 119228, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Rebecca JM Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Joline SJ Lim
- Department of Haematology-Oncology, National University Cancer Institute, National University Hospital, Singapore 119228, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
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7
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Mohamed A, Kruse M, Tran J. Progress in immune checkpoint inhibition in early-stage triple-negative breast cancer. Expert Rev Anticancer Ther 2023; 23:1071-1084. [PMID: 37747062 DOI: 10.1080/14737140.2023.2262764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/20/2023] [Indexed: 09/26/2023]
Abstract
INTRODUCTION Immune checkpoint inhibitors have been particularly effective in treating cancers with robust immune microenvironments and have been successfully incorporated into the management of metastatic ER-negative and HER2-negative breast cancer. This has prompted investigation of immunotherapy in early-stage triple negative breast cancer (TNBC) to address the suboptimal clinical outcomes and limited therapeutic options. AREAS COVERED This review highlights the studies examining the use of neoadjuvant immunotherapy with standard chemotherapy in the management of early-stage TNBC and explores ongoing areas of study including the role of adjuvant checkpoint inhibition and novel combination therapies with immunotherapy. EXPERT OPINION The current standard of care for early-stage ER-negative, HER2-negative breast cancer measuring ≥2 cm or with lymph node involvement is neoadjuvant chemotherapy with pembrolizumab followed by ongoing pembrolizumab in the adjuvant setting to complete 1 year of total therapy as per the KEYNOTE-522 study. This approach is associated with improved pathologic complete response (pCR) rate and event free survival, irrespective of PD-L1 status. Many questions remain regarding the optimization of chemotherapy partner(s) for immunotherapy, necessity of adjuvant immunotherapy for patients who achieve pCR, inclusion of other therapies in the adjuvant setting (particularly capecitabine or olaparib), and use of adjuvant immunotherapy when it was not received in the neoadjuvant setting.
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Affiliation(s)
- Ahmed Mohamed
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, United States of America
| | - Megan Kruse
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, United States of America
| | - Jennifer Tran
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, United States of America
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Guven DC, Yildirim HC, Kus F, Erul E, Kertmen N, Dizdar O, Aksoy S. Optimal adjuvant treatment strategies for TNBC patients with residual disease after neoadjuvant treatment. Expert Rev Anticancer Ther 2023; 23:1049-1059. [PMID: 37224429 DOI: 10.1080/14737140.2023.2218090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 05/22/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION The therapeutic armamentarium for the neoadjuvant treatment of triple-negative breast cancer (TNBC) has significantly expanded with the hopes of improving pathological complete response (pCR) rates and the possibility of a cure. However, the data on optimal adjuvant treatment strategies for patients with residual disease after neoadjuvant treatment is limited. AREAS COVERED We discuss the available data on adjuvant treatment for residual TNBC after neoadjuvant treatment considering clinical trials. Additionally, we discuss ongoing trials to give perspectives on how the field may evolve in the next decade. EXPERT OPINION The available data support the use of adjuvant capecitabine for all patients and either adjuvant capecitabine or olaparib for patients with germline BRCA1 and BRCA2 mutations, according to availability. The CREATE-X study of capecitabine and OlympiA study of olaparib demonstrated disease-free and overall survival benefits. There is an unmet need for studies comparing these two options for patients with germline BRCA mutations. Further research is needed to delineate the use of immunotherapy in the adjuvant setting, molecular targeted therapy for patients with molecular alterations other than germline BRCA mutation, combinations, and antibody-drug conjugates to further improve outcomes.
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Affiliation(s)
- Deniz Can Guven
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Hasan Cagri Yildirim
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Fatih Kus
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Enes Erul
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Neyran Kertmen
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Omer Dizdar
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Sercan Aksoy
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
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Voorwerk L, Sanders J, Keusters MS, Balduzzi S, Cornelissen S, Duijst M, Lips EH, Sonke GS, Linn SC, Horlings HM, Kok M. Immune landscape of breast tumors with low and intermediate estrogen receptor expression. NPJ Breast Cancer 2023; 9:39. [PMID: 37179445 PMCID: PMC10182974 DOI: 10.1038/s41523-023-00543-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
Immune checkpoint blockade (ICB) is currently approved for patients with triple-negative breast cancer (TNBC), whereas responses to ICB are also observed in a small subgroup of Estrogen Receptor (ER)-positive breast cancer. The cut-off for ER-positivity (≥1%) is based on likelihood of endocrine treatment response, but ER-positive breast cancer represents a very heterogeneous group. This raises the question whether selection based on ER-negativity should be revisited to select patients for ICB treatment in the context of clinical trials. Stromal tumor-infiltrating lymphocytes (sTILs) and other immune parameters are higher in TNBC compared to ER-positive breast cancer, but it is unknown whether lower ER levels are associated with more inflamed tumor microenvironments (TME). We collected a consecutive series of primary tumors from 173 HER2-negative breast cancer patients, enriched for tumors with ER expression between 1 and 99% and found levels of stromal TILs, CD8 + T cells, and PD-L1 positivity in breast tumors with ER 1-9% and ER 10-50% to be comparable to tumors with ER 0%. Expression of immune-related gene signatures in tumors with ER 1-9% and ER 10-50% was comparable to ER 0%, and higher than in tumors with ER 51-99% and ER 100%. Our results suggest that the immune landscape of ER low tumors (1-9%) and ER intermediate tumors (10-50%) mimic that of primary TNBC.
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Affiliation(s)
- Leonie Voorwerk
- Division of Tumor Biology & Immunology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Joyce Sanders
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Milou S Keusters
- Division of Tumor Biology & Immunology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Sara Balduzzi
- Department of Biometrics, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Sten Cornelissen
- Core Facility Molecular Pathology & Biobanking, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Maxime Duijst
- Division of Tumor Biology & Immunology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Esther H Lips
- Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Sabine C Linn
- Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hugo M Horlings
- Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Marleen Kok
- Division of Tumor Biology & Immunology, Netherlands Cancer Institute, Amsterdam, the Netherlands.
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.
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10
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Emens LA, Loi S. Immunotherapy Approaches for Breast Cancer Patients in 2023. Cold Spring Harb Perspect Med 2023; 13:13/4/a041332. [PMID: 37011999 PMCID: PMC10071416 DOI: 10.1101/cshperspect.a041332] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Immunotherapy, particularly agents targeting the immunoregulatory PD-1/PD-L1 axis, harnesses the power of the immune system to treat cancer, with unique potential for a durable treatment effect due to immunologic memory. The PD-1 inhibitor pembrolizumab combined with neoadjuvant chemotherapy followed by adjuvant pembrolizumab improves event-free survival and is a new standard of care for high-risk, early-stage triple-negative breast cancer (TNBC), regardless of tumor PD-L1 expression. For metastatic TNBC, pembrolizumab combined with chemotherapy is a new standard of care for the first-line therapy of PD-L1+ metastatic TNBC, with improvement in overall survival. The PD-L1 inhibitor atezolizumab combined with nab-paclitaxel is also approved outside the United States for the first-line treatment of metastatic PD-L1+ TNBC. Current research focuses on refining the use of immunotherapy in TNBC by defining informative predictive biomarkers, developing immunotherapy in early and advanced HER2-driven and luminal breast cancers, and overcoming primary and secondary resistance to immunotherapy through unique immune-based strategies.
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Affiliation(s)
- Leisha A Emens
- Department of Medicine, University of Pittsburgh/UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania 15232, USA
- Ankyra Therapeutics, Boston, Massachusetts 02116, USA
| | - Sherene Loi
- The Sir Peter MacCallum Department of Medical Oncology, University of Melbourne, Parkville, Victoria 3010, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia
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11
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Yang T, Li W, Huang T, Zhou J. Immunotherapy Targeting PD-1/PD-L1 in Early-Stage Triple-Negative Breast Cancer. J Pers Med 2023; 13:jpm13030526. [PMID: 36983708 PMCID: PMC10055616 DOI: 10.3390/jpm13030526] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
The advent of immunotherapy, especially immune checkpoint inhibitors (ICIs), has revolutionized antitumor therapy. Programmed cell death receptor 1 (PD-1) and programmed cell death ligand 1 (PD-L1) are among the most promising targets for encouraging the immune system to eliminate cancer cells. PD-1/PD-L1 have made clinical remission for numerous solid tumors, including metastatic triple-negative breast cancer (TNBC). In recent years, integrating PD-1/PD-L1 inhibitors into existing treatments in early-stage TNBC has attracted wide attention. Herein, we summarize the clinical benefit of PD-1/PD-L1 inhibitors plus neoadjuvant chemotherapy, adjuvant chemotherapy, and targeted therapy in early-stage TNBC. Possible immunotherapy biomarkers, immune-related adverse events (irAEs), and the key challenges faced in TNBC anti-PD-1/PD-L1 therapy are also concluded. Numerous studies on immunotherapy are ongoing, and PD-1/PD-L1 inhibitors have demonstrated great clinical prospects in early-stage TNBC. To maximize the efficacy of anti-PD-1/PD-L1 therapy, further research into the challenges which still exist is necessary.
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12
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Zaakouk M, Van Bockstal M, Galant C, Callagy G, Provenzano E, Hunt R, D’Arrigo C, Badr NM, O’Sullivan B, Starczynski J, Tanchel B, Mir Y, Lewis P, Shaaban AM. Inter- and Intra-Observer Agreement of PD-L1 SP142 Scoring in Breast Carcinoma-A Large Multi-Institutional International Study. Cancers (Basel) 2023; 15:cancers15051511. [PMID: 36900303 PMCID: PMC10000421 DOI: 10.3390/cancers15051511] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/15/2023] [Accepted: 02/24/2023] [Indexed: 03/04/2023] Open
Abstract
The assessment of PD-L1 expression in TNBC is a prerequisite for selecting patients for immunotherapy. The accurate assessment of PD-L1 is pivotal, but the data suggest poor reproducibility. A total of 100 core biopsies were stained using the VENTANA Roche SP142 assay, scanned and scored by 12 pathologists. Absolute agreement, consensus scoring, Cohen's Kappa and intraclass correlation coefficient (ICC) were assessed. A second scoring round after a washout period to assess intra-observer agreement was carried out. Absolute agreement occurred in 52% and 60% of cases in the first and second round, respectively. Overall agreement was substantial (Kappa 0.654-0.655) and higher for expert pathologists, particularly on scoring TNBC (6.00 vs. 0.568 in the second round). The intra-observer agreement was substantial to almost perfect (Kappa: 0.667-0.956), regardless of PD-L1 scoring experience. The expert scorers were more concordant in evaluating staining percentage compared with the non-experienced scorers (R2 = 0.920 vs. 0.890). Discordance predominantly occurred in low-expressing cases around the 1% value. Some technical reasons contributed to the discordance. The study shows reassuringly strong inter- and intra-observer concordance among pathologists in PD-L1 scoring. A proportion of low-expressors remain challenging to assess, and these would benefit from addressing the technical issues, testing a different sample and/or referring for expert opinions.
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Affiliation(s)
- Mohamed Zaakouk
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Cancer Pathology, National Cancer Institue, Cairo University, Cairo 12613, Egypt
| | - Mieke Van Bockstal
- Department of Pathology, Cliniques Universitaires Saint-Luc Bruxelles, 1200 Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1348 Brussels, Belgium
| | - Christine Galant
- Department of Pathology, Cliniques Universitaires Saint-Luc Bruxelles, 1200 Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1348 Brussels, Belgium
| | - Grace Callagy
- Discipline of Pathology, School of Medicine, Lambe Institute for Translational Research, University of Galway, H91 TK33 Galway, Ireland
| | - Elena Provenzano
- NIHR Cambridge Biomedical Research Centre, Cambridge CB2 0QQ, UK
- Addenbrookes Hospital, Cambridge CB2 0QQ, UK
- Department of Histopathology, Cambridge University NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Roger Hunt
- Department of Histopathology, Wythenshawe Hospital, Manchester M23 9LT, UK
| | | | - Nahla M. Badr
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Department of Pathology, Faculty of Medicine, Menoufia University, Shebin El-Kom 32952, Egypt
| | - Brendan O’Sullivan
- Cellular Pathology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - Jane Starczynski
- Cellular Pathology, Heart of England NHS Foundation Trust, Birmingham B9 5ST, UK
| | - Bruce Tanchel
- Cellular Pathology, Heart of England NHS Foundation Trust, Birmingham B9 5ST, UK
| | - Yasmeen Mir
- Pathology, Royal Liverpool and Broadgreen University Hospitals, Liverpool L7 8YE, UK
| | - Paul Lewis
- Medical School, Swansea University, Singleton Park, Swansea SA2 8PP, UK
| | - Abeer M. Shaaban
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Cellular Pathology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
- Correspondence: ; Tel.: +44-121-371-3356
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13
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Wu J, Chen Y, Chen L, Ji Z, Tian H, Zheng D, Yang Q, Liu Y, Cai J, Zheng J, Chen Y, Li Z. Global research trends on anti-PD-1/anti-PD-L1 immunotherapy for triple-negative breast cancer: A scientometric analysis. Front Oncol 2023; 12:1002667. [PMID: 36713507 PMCID: PMC9875294 DOI: 10.3389/fonc.2022.1002667] [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: 08/08/2022] [Accepted: 12/15/2022] [Indexed: 01/12/2023] Open
Abstract
In recent years, anti-PD-1/anti-PD-L1 has been considered to be a valuable therapeutic target and prognostic indicator for triple-negative breast cancer. We analyzed all publications published in the field from their inception until the present day in order to determine the current research status and hotspots. All related publications were searched on the Web of Science. Our research used R-studio (bibliometrix package), VOSviewer, and CiteSpace to analyze and obtain annual publications and citation information, articles, highest publication countries and affiliations, influential journals and authors, keyword analysis, and keyword bursts. In total, 851 documents were retrieved including 628 articles and 223 review articles. The output of publications increased year by year from 2013 to 2021. However, the average article citation times reached the top in 2014 but generally showed a downward trend from 2014 to 2021. It was an article written by Schmid et al. in 2018 that received the most citations. With regard to publications, citations, and link strength, among the top countries was the United States. Cancers was the most published journal. Schmid and Loi ranked top in total citations and h-index. Schmid has the largest M-index and Loi has the most publication. The keywords that received the most attention were "Immunotherapy", "PD-L1", "Triple-negative breast cancer", "Tumor-infiltrating lymphocytes", and "Expression". According to the report, this current research focuses on immunotherapy for triple-negative breast cancer and the expression of PD-L1 and tumor-infiltrating lymphocytes (TILs). Pembrolizumab and Atezolizumab plus chemotherapy have completed the Phase 3 clinical trial. However, the biomarkers were limited in predicting the treatment prognosis. Through the scientometric analysis, we can understand the current research status and potential research points in this filed and provide research direction for researchers.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Yexi Chen
- *Correspondence: Yexi Chen, ; Zhiyang Li,
| | - Zhiyang Li
- *Correspondence: Yexi Chen, ; Zhiyang Li,
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14
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Li L, Zhang F, Liu Z, Fan Z. Immunotherapy for Triple-Negative Breast Cancer: Combination Strategies to Improve Outcome. Cancers (Basel) 2023; 15:cancers15010321. [PMID: 36612317 PMCID: PMC9818757 DOI: 10.3390/cancers15010321] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/27/2022] [Accepted: 12/29/2022] [Indexed: 01/05/2023] Open
Abstract
Due to the absence of hormone receptor (both estrogen receptors and progesterone receptors) along with human epidermal growth factor receptor 2 (HER-2) amplification, the treatment of triple-negative breast cancer (TNBC) cannot benefit from endocrine or anti-HER-2 therapy. For a long time, chemotherapy was the only systemic treatment for TNBC. Due to the lack of effective treatment options, the prognosis for TNBC is extremely poor. The successful application of immune checkpoint inhibitors (ICIs) launched the era of immunotherapy in TNBC. However, the current findings show modest efficacy of programmed cell death- (ligand) 1 (PD-(L)1) inhibitors monotherapy and only a small proportion of patients can benefit from this approach. Based on the basic principles of immunotherapy and the characteristics of the tumor immune microenvironment (TIME) in TNBC, immune combination therapy is expected to further enhance the efficacy and expand the beneficiary population of patients. Given the diversity of drugs that can be combined, it is important to select effective biomarkers to identify the target population. Moreover, the side effects associated with the combination of multiple drugs should also be considered.
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15
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Varma R, Wright M, Abraham J, Kruse M. Immune checkpoint inhibition in early-stage triple-negative breast cancer. Expert Rev Anticancer Ther 2022; 22:1225-1238. [PMID: 36278877 DOI: 10.1080/14737140.2022.2139240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Breast cancer cells can evade immune recognition by upregulating programmed death-ligand 1 (PD-L1) leading to decreased T cell function. Anti-PD-1 agents, like pembrolizumab, and anti-PD-L1 agents, such as atezolizumab and durvalumab, in combination with chemotherapy were found to have efficacy in metastatic triple-negative breast cancer (TNBC). With sub-optimal long-term outcomes in early-stage TNBC, this combination of immune checkpoint inhibition with chemotherapy was subsequently investigated. A robust immune microenvironment and extensive tumor antigen exposure in early-stage breast cancer is believed to facilitate response to checkpoint inhibitors. AREAS COVERED This review focuses on studies that assess the role of neoadjuvant immune checkpoint inhibition along with chemotherapy. The results of key phase I, II and III trials using checkpoint inhibitors in early-stage breast cancer (ESBC) are reviewed along with foundational data from metastatic TNBC, including the role of biomarkers in predicting response to immunotherapy. EXPERT OPINION Despite a clear role for neoadjuvant immune checkpoint inhibition in TNBC, many questions remain. The benefit of these agents in the neoadjuvant versus adjuvant setting is unclear and immune-related toxicity is a major concern. Additional studies are needed to elucidate which immune checkpoint inhibitor is most efficacious and best tolerated in early-stage TNBC.
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Affiliation(s)
- Revati Varma
- Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Matthew Wright
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio, United States
| | - Jame Abraham
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio, United States
| | - Megan Kruse
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio, United States
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16
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Lu JY, Alvarez Soto A, Anampa JD. The landscape of systemic therapy for early stage triple negative breast cancer. Expert Opin Pharmacother 2022; 23:1291-1303. [PMID: 35818711 DOI: 10.1080/14656566.2022.2095902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
INTRODUCTION Triple negative breast cancer (TNBC) is the most aggressive subtype of breast cancer with higher risk of disease recurrence and mortality than other breast cancer subtypes. Historically, chemotherapy has been the primary systemic treatment for early stage TNBC. Recent developments in immune checkpoint inhibitors (ICIs) and novel therapeutic agents have transformed the treatment of TNBC. AREAS COVERED This review provides a comprehensive overview of the current evidence on treatment of early stage TNBC. We highlight the incorporation of ICIs and other targeted therapies in (neo)adjuvant treatment and the ongoing development of novel therapeutic agents. EXPERT OPINION The landscape of early TNBC treatment is rapidly evolving which has given rise to the introduction of ICIs and PARP inhibitors into the systemic therapy. Despite modest improvement in pathologic complete response (pCR) rate, ICI plus chemotherapy significantly improves long-term outcomes and is now used in (neo)adjuvant treatment of patients with TNBC and high risk for disease recurrence. Capecitabine remains the standard adjuvant treatment for residual disease, with olaparib being an option for patients with germline BRCA1/2 mutations. Early detection of minimal residual disease may identify patients requiring additional therapy to prevent recurrence.
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Affiliation(s)
- Jin-Yu Lu
- Department of Oncology, Section of Breast Medical Oncology, Albert Einstein Cancer Center, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10461, USA
| | - Alvaro Alvarez Soto
- Department of Oncology, Section of Breast Medical Oncology, Albert Einstein Cancer Center, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10461, USA
| | - Jesus D Anampa
- Department of Oncology, Section of Breast Medical Oncology, Albert Einstein Cancer Center, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10461, USA
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17
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Giugliano F, Valenza C, Tarantino P, Curigliano G. Immunotherapy for triple negative breast cancer: How can pathologic responses to experimental drugs in early-stage disease be enhanced? Expert Opin Investig Drugs 2022; 31:855-874. [PMID: 35762248 DOI: 10.1080/13543784.2022.2095260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : The treatment landscape of early triple negative breast cancer (TNBC) has recently expanded after the Food and Drug Administration (FDA) approval of pembrolizumab in combination with neoadjuvant chemotherapy. The addition of this immune checkpoint inhibitor (ICI) has shown to significantly increased pathological complete response (pCR) rate and event free survival (EFS) in the KEYNOTE-522 phase 3 trial. Several additional studies are ongoing with the goal of further improving outcomes and achieving an optimal integration of ICIs in the treatment of TNBC. AREAS COVERED : The article examines pCR and survival rates in TNBC. It appraises clinical trials investigating neoadjuvant ICIs for TNBC and the improvement of pCR rates (biomarker-driven escalation of treatment, optimization of chemotherapy backbone and addition of locoregional treatments or innovative agents). Insights on the role of pCR as surrogate endpoint and the possibility of enhancing pCR rates for women affected by early TNBC are offered. EXPERT OPINION : The pharmacopoeia of early TNBC is growing and becoming more heterogeneous with the advent of ICIs; to enhance the clinical benefit of patients, it is necessary to develop response endpoints that consider the mechanism of action of experimental drugs, to optimize patient selection through validated biomarkers, and to compare the most promising treatment strategies in randomized clinical trials.
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Affiliation(s)
- Federica Giugliano
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy.,Department of Oncology and Haematology, University of Milan, Milan, Italy
| | - Carmine Valenza
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy.,Department of Oncology and Haematology, University of Milan, Milan, Italy
| | - Paolo Tarantino
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy.,Department of Oncology and Haematology, University of Milan, Milan, Italy.,Breast Oncology Center, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy.,Department of Oncology and Haematology, University of Milan, Milan, Italy
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18
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Biomarkers Changes after Neoadjuvant Chemotherapy in Breast Cancer: A Seven-Year Single Institution Experience. Diagnostics (Basel) 2021; 11:diagnostics11122249. [PMID: 34943486 PMCID: PMC8700750 DOI: 10.3390/diagnostics11122249] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 11/22/2021] [Accepted: 11/26/2021] [Indexed: 12/21/2022] Open
Abstract
The adoption of neoadjuvant chemotherapy (NACT) for breast cancer (BC) is increasing. The need to repeat the biomarkers on a residual tumor after NACT is still a matter of debate. We verified estrogen receptors (ER), progesterone receptors (PR), Ki67 and human epidermal growth factor receptor 2 (HER2) status changes impact in a retrospective monocentric series of 265 BCs undergoing NACT. All biomarkers changed with an overall tendency toward a reduced expression. Changes in PR and Ki67 were statistically significant (p = 0.001). Ki67 changed in 114/265 (43.0%) cases, PR in 44/265 (16.6%), ER in 31/265 (11.7%) and HER2 in 26/265 (9.8%). Overall, intrinsic subtype changed in 72/265 (27.2%) cases after NACT, and 10/265 (3.8%) cases switched to a different adjuvant therapy accordingly. Luminal subtypes changed most frequently (66/175; 31.7%) but with less impact on therapy (5/175; 2.8%). Only 3 of 58 triple-negative BCs (5.2%) changed their intrinsic subtype, but all of them switched treatment. No correlation was found between intrinsic subtype changes and clinicopathological features. To conclude, biomarkers changes with prognostic implications occurred in all BC intrinsic subtypes, albeit they impacted therapy mostly in HER2 negative and/or hormone receptors negative BCs. Biomarkers retesting after NACT is important to improve both tailored adjuvant therapies and prognostication of patients.
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19
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Dieci MV, Griguolo G, Bottosso M, Tsvetkova V, Giorgi CA, Vernaci G, Michieletto S, Angelini S, Marchet A, Tasca G, Genovesi E, Cumerlato E, Lo Mele M, Conte P, Guarneri V. Impact of estrogen receptor levels on outcome in non-metastatic triple negative breast cancer patients treated with neoadjuvant/adjuvant chemotherapy. NPJ Breast Cancer 2021; 7:101. [PMID: 34341356 PMCID: PMC8329161 DOI: 10.1038/s41523-021-00308-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 06/25/2021] [Indexed: 12/13/2022] Open
Abstract
Although 1% is the recommended cut-off to define estrogen receptor (ER) positivity, a 10% cut-off is often used in clinical practice for therapeutic purposes. We here evaluate clinical outcomes according to ER levels in a monoinstitutional cohort of non-metastatic triple-negative breast cancer (BC) patients undergoing (neo)adjuvant chemotherapy. Clinicopathological data of 406 patients with ER < 10% HER2-negative BC treated with (neo)adjuvant chemotherapy between 01/2000 and 04/2019 were collected. Patients were categorized in ER-negative (ER < 1%; N = 364) and ER-low positive (1-9%, N = 42). At a median follow-up of 54 months, 88 patients had relapsed and 64 died. No significant difference was observed in invasive relapse-free survival (iRFS) and overall survival (OS) according to ER expression levels, both at univariate and multivariate analysis (5-years iRFS 74.0% versus 73.1% for ER-negative and ER-low positive BC, respectively, p = 0.6; 5-years OS 82.3% versus 76.7% for ER-negative and ER-low positive BC, respectively, p = 0.8). Among the 165 patients that received neoadjuvant chemotherapy, pathological complete response rate was similar in the two cohorts (38% in ER-negative, 44% in ER-low positive, p = 0.498). In conclusion, primary BC with ER1-9% shows similar clinical behavior to ER 1% BC. Our results suggest the use of a 10% cut-off, rather than <1%, to define triple-negative BC.
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Affiliation(s)
- Maria Vittoria Dieci
- Division of Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Gaia Griguolo
- Division of Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Michele Bottosso
- Division of Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | | | | | - Grazia Vernaci
- Division of Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | | | - Silvia Angelini
- Division of Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy
| | - Alberto Marchet
- Clinica Chirurgica 1, Azienda Ospedaliera di Padova, Padova, Italy
| | - Giulia Tasca
- Division of Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy
| | - Elisa Genovesi
- Division of Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Enrico Cumerlato
- Division of Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Marcello Lo Mele
- Department of Pathology, Azienda Ospedaliera di Padova, Padova, Italy
| | - PierFranco Conte
- Division of Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Valentina Guarneri
- Division of Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy.
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.
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20
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Zhu Y, Zhu X, Tang C, Guan X, Zhang W. Progress and challenges of immunotherapy in triple-negative breast cancer. Biochim Biophys Acta Rev Cancer 2021; 1876:188593. [PMID: 34280474 DOI: 10.1016/j.bbcan.2021.188593] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 06/26/2021] [Accepted: 07/14/2021] [Indexed: 12/12/2022]
Abstract
Triple-negative breast cancer (TNBC), a subtype of breast cancer, is defined as lacking estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 (HER2) expression. Compared with other subtypes in breast cancer, TNBC is more likely to recur and metastasize, with a lower survival rate. Due to the absence of definitive targets, there was limited novel therapeutic interventions and chemotherapy remained the primary treatment in the past decades. Following the development of immune checkpoint inhibition (ICI) in solid tumors and validation of the immunogenicity in TNBC, immunotherapy has attracted more and more attentions. On basis of accumulating clinical studies, we reviewed the current progress targeting different immune checkpoints in several-lines treatment for TNBC, including programmed death-1 (PD-1)/programmed death ligand-1 (PD-L1) inhibitors, cytotoxic T-lymphocyte associated antigen-4 (CTLA-4) inhibitor, and other novel immunotherapeutic approaches (e.g., individualized peptide vaccine, cancer-testis antigen (CTA), new antigen vaccine, RNA vaccine and chimeric antigen receptor modified T cells (CAR-T)). In order to improve the survival outcome of TNBC populations, we further discussed potential predictive biomarkers for immunotherapy (e.g., PD-L1 expression, tumor mutational burden (TMB), tumor-infiltrating lymphocytes (TILs), microsatellite instability (MSI)/mismatch repair (MMR) deficiency) and challenges in the future treatment of TNBC.
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Affiliation(s)
- Yinxing Zhu
- Department of Oncology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Xuedan Zhu
- Department of Oncology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Cuiju Tang
- Department of Oncology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China.
| | - Xiaoxiang Guan
- Department of Oncology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China; Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Personalized Cancer Medicine, Nanjing Medical University, Nanjing 211166, China.
| | - Wenwen Zhang
- Department of Oncology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China.
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21
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Nelson MA, Ngamcherdtrakul W, Luoh SW, Yantasee W. Prognostic and therapeutic role of tumor-infiltrating lymphocyte subtypes in breast cancer. Cancer Metastasis Rev 2021; 40:519-536. [PMID: 33963482 PMCID: PMC8424653 DOI: 10.1007/s10555-021-09968-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/21/2021] [Indexed: 02/06/2023]
Abstract
Increased levels of total tumor-infiltrating lymphocytes (TILs) are generally associated with good prognosis in several breast cancer subtypes. Subtypes of TILs impact both tumor cells and immune cells in a variety of different ways, leading to either a pro-tumor or antitumor effect. Tumor-infiltrating CD8+ T cells and natural killer (NK) cells perform as effector cells against tumor cells and are associated with better clinical outcome. Immunotherapy approaches that improve the antitumor activity and proliferation of CD8+ T and NK cells include PD-1/PD-L1 blockade, CAR T cell therapy, or ex vivo-stimulated NK cells. A subset of CD8+ T cells, tissue-resident memory T cells, has also recently been associated with good prognosis in breast cancer patients, and has potential to serve as a predictive biomarker and therapeutic target. Tumor-infiltrating B cells also secrete apoptosis-inducing IgG antibodies and can act as antigen-presenting cells to prime CD4+ and CD8+ T cells. On the other hand, regulatory T and regulatory B cells modulate the immune response from CD8+ T cells and NK cells by secreting immunosuppressive cytokines and inhibiting maturation of antigen-presenting cells (APCs). These regulatory cells are typically associated with poor prognosis, therefore rendering suppression of their regulatory function a key immunotherapeutic strategy.
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Affiliation(s)
| | | | - Shiuh-Wen Luoh
- VA Portland Health Care System, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Wassana Yantasee
- PDX Pharmaceuticals, Inc., Portland, OR, USA.
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, OR, USA.
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