Discordance of the estrogen receptor and HER-2/neu in breast cancer from primary lesion to first and second metastatic site

Molecular subtype conversion in CTCs as indicator of treatment adequacy associated with metastasis-free survival in breast cancer

Molecular subtype of breast cancer has a great clinical significance and used as one of the major criteria for therapeutic strategy. Recently, for anticancer therapy, the trend for oncologists is the predominant determination of biomarkers in the existing foci of the disease. In the case of adjuvant therapy prescribed for distant metastases prevention, CTCs could be a suitable object for investigation. CTCs as one of the factors responsible for tumor metastatic potential could be more convenient and informative for evaluation of hormone receptors, Ki-67 and HER2 expression, which are determine molecular subtype in breast cancer patient. In our study, we aimed to investigate the molecular subtype discordance between the primary tumor and CTCs in breast cancer patients. We established conversion of molecular subtype in most of the cases. Namely, conversion was detected in 90% of untreated patients and in 82% of breast cancer patients treated by neoadjuvant chemotherapy. At the same time, molecular subtype conversions in patients treated by neoadjuvant chemotherapy were more diverse. Molecular subtype conversions resulted more often in the unfavorable variants in circulating tumor cells. We stratified all patients according to the adequacy of treatment against converted CTCs molecular subtype. Our study revealed that good response to neoadjuvant chemotherapy observed in case of adequate therapy, namely, when chemotherapy scheme was sufficient against CTCs. It turned out that patients with inadequate therapy were characterized by decreased simulated 5-year metastasis-free survival compared to patients who received appropriate therapy. Thus, detection of molecular subtype conversion in circulating tumor cells could be a perspective tool for optimization of antitumor therapy.

Clinical possibilities of HER2-positive breast cancer diagnosis using alternative scaffold proteins

HER2-positive breast cancer occurs in 15–20% of breast cancer patients and is associated primarily with a poor prognosis of the disease and the need for highly specific targeted therapy. Despite the clinical importance of determining HER2/neu, traditional diagnostic methods have their disadvantages and require the study of new additional research techniques.

The information presented in this review makes it possible to consider current trends in the radionuclide diagnosis of HER2-positive breast cancer using the latest class of alternative scaffold proteins and to consider various aspects of their use in clinical practice.

The Evolution of Targeted Radionuclide Diagnosis of HER2-Positive Breast Cancer

This review examines the evolution of the radionuclide diagnosis of HER2-positive breast cancer using various compounds as a targeting module in clinical practice: from full-length antibodies to a new group of small synthetic proteins called alternative scaffold proteins. This topic is of especial relevance today in view of the problems attendant to the detection of breast cancer with HER2/neu overexpression, which, in most cases, introduce errors in the treatment of patients. The results of clinical studies of radiopharmaceuticals based on affibody molecules, ADAPTs, and DARPins for SPECT and PET have demonstrated good tolerability of the compounds, their rapid excretion from the body, and the possibility to differentiate tumor sites depending on the HER2/neu status. This indicates that targeted radionuclide diagnosis holds promise and the need to continue research in this direction.

Novel ADCs and Strategies to Overcome Resistance to Anti-HER2 ADCs

During recent years, a number of new compounds against HER2 have reached clinics, improving the prognosis and quality of life of HER2-positive breast cancer patients. Nonetheless, resistance to standard-of-care drugs has motivated the development of novel agents, such as new antibody-drug conjugates (ADCs). The latter are a group of drugs that benefit from the potency of cytotoxic agents whose action is specifically guided to the tumor by the target-specific antibody. Two anti-HER2 ADCs have reached the clinic: trastuzumab-emtansine and, more recently, trastuzumab-deruxtecan. In addition, several other HER2-targeted ADCs are in preclinical or clinical development, some of them with promising signs of activity. In the present review, the structure, mechanism of action, and potential resistance to all these ADCs will be described. Specific attention will be given to discussing novel strategies to circumvent resistance to ADCs.

Receptor conversion impacts outcomes of different molecular subtypes of primary breast cancer

Background

Although the conversion of clinically used breast cancer biomarkers such as estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) between primary tumors and metastatic lesions is well recognized, data on whether receptor conversion has an effect on therapy management and survival in patients with metastatic breast cancer is limited. This study aimed to investigate the clinical implications of receptor conversion throughout tumor progression.

Methods

In total, 2450 patients diagnosed with metastatic breast cancer in Tianjin Medical University Cancer Institute and Hospital were analyzed and 426 female patients with available biopsy results from both primary and metastatic sites were included in this study. We investigated the alteration of ER, PR and HER2 during breast cancer progression and evaluated the therapy management and prognostic value of receptor conversion.

Results

The conversion rates of ER, PR, and HER2 between primary tumors and metastasis were 21.1% (McNemar's test p < 0.001), 33.2% (p < 0.001), and 11.6% (p = 0.868), respectively. Evaluation of ER, PR, and HER2 status in multiple consecutive metastases revealed a change in 19.1% (p > 0.05), 23.5% (p = 0.021), and 9.8% (p > 0.05) of patients, respectively. Adjuvant therapy (chemotherapy/endocrine therapy) was related to hormone receptor conversion (p < 0.05). A statistically significant differential survival associated with hormone receptor (ER/PR) conversion (log-rank p < 0.05) was observed. In the multivariate analysis, ER conversion was an independent influence factor of survival (p < 0.05). Molecular typing conversion in primary and metastatic lesions also had a significant effect on survival (p < 0.05). We found that changing treatment based on the receptor conversion could affect clinical outcomes (p < 0.05).

Conclusions

Our findings indicated that receptor conversion during breast tumor progression had a significant effect on survival. Most importantly, our findings proved that patients with receptor conversion benefited from a change in therapy.

Breast Cancer Brain Metastasis: The Potential Role of MRI Beyond Current Clinical Applications

PURPOSE

Breast cancer brain metastasis (BCBM) represents a major clinical challenge. Can MRI help in advancements in the management of BCBM? This review discusses MRI developments and the corresponding potential advancements in BCBM management.

METHODS

An exhaustive literature search was undertaken to identify studies which look into the potential of MRI in BCBM management. Seven hundred and eighty-four studies published from September 1984 to May 2020 were identified. Three topics are covered where MRI is not clinically established yet: 1) the prognosis of BCBM; 2) the screening of BC patients for BCBM development, and 3) the assessment of imaging features correlated to BC subtype.

RESULTS

Thirty-six studies were considered eligible for the purposes of this review. On-going progress is made with the identification of different BCBM characteristics and MRI metrics that might be related to prognosis. Progress has been made with the identification of different BCBM characteristics, including BCBM location, degree of edema, white matter disruption, tumor edge sharpness, and temporal muscle thickness. A more accurate prediction of prognosis could lead to more suitable patient management and treatment. The use of MRI in BCBM screening of the high-risk breast cancer population remains a controversial subject. To date, there are no results from clinical trials; however, there is a rising number of relatively small studies that show concern on this subject and support BCBM screening. It is important to oncologists to be able to assess the tumor subtype non-invasively. MRI features, which have shown some correlation with subtype, include the number of tumors, location, and their distribution in the brain. Advanced tools and metrics have been produced to carry out radiological characteristics analysis on MRI images. Assessing MRI features in more detail could provide a more personalized management of patients.

CONCLUSION

Developments in the use of MRI have the potential to improve BCBM management.

The Case to Case Comparison of Hormone Receptors and HER2 Status between Primary Breast Cancer and Synchronous Axillary Lymph Node Metastasis

Background:

Nowadays, the adjuvant treatment for breast cancer patients chosen depends on immunohistochemical pattern of Estrogen receptor(ER), Progesterone receptor(PR) and HER2 status of primary breast tumor. Several retrospective studies showed significant discordance in receptor expression between primary and metastatic tumors. The objective of this research was to determine discordant rate of ER, PR and HER2 status between primary breast cancer and synchronous axillary lymph node metastasis of individual breast cancer patients in Thammasat University Hospital.

Methods:

A prospective observational study of all breast cancer patients who have axillary metastasis and underwent surgery at Thammasat Hospital between January 2011 to December 2015. Tumor staging, ER, PR, and HER2 status on primary breast tumor were recorded. Synchronous axillary lymph node metastasis was evaluated with immunohistochemistry for ER, PR, and HER2.

Results:

The ER-positive rate from primary tumor to synchronous axillary lymph node metastasis decreased from 74.7% to 71.7%; the HER2 overexpression rate was decreased from 26% to 24%. In contrast, PR positive rate were 71% in both primary tumor and synchronous axillary lymph node metastasis. In case to case comparison, discordance rate of ER, PR and HER2 status between primary breast cancer and synchronous axillary lymph node metastasis were 11.1%, 20.2% and 10.1%, respectively. Furthermore, the tumor staging was not significant associated with discordance of ER, PR and HER2.

Conclusion:

ER, PR and HER 2 biomarkers showed significant concordance between primary tumor and synchronous axillary lymph node metastasis. Hence, if we cannot assess the ER, PR and HER2 status in primary tumor, then synchronous axillary lymph node metastasis can be studied instead. However, the repeat of biomarker testing in node-positive breast cancer patients may be beneficial for tailored adjuvant therapy, especially for patients with negative hormone receptor and/or HER2 profile on primary tumor.

The Prognostic Impact of Hormonal Receptor and HER-2 Expression Discordance in Metastatic Breast Cancer Patients

Background

Hormone receptor (HR) and human epidermal growth factor receptor (HER2) discordance between primary and metastatic breast cancer lesions is common. However, its impact on long-term survival remains unclear. We aimed to determine the prognostic value of this discordance in patients with metastaticf breast cancer (MBC).

Methods

A total of 270 patients with MBC who were underwent re-biopsy of progressive metastases at Zhejiang Cancer Hospital from January 1, 2012 to December 31, 2015 with patients consent and then review their primary tumors pathological findings. The HR and HER2 status in both primary and progressive metastatic lesions was determined by immunohistochemistry and/or fluorescence in situ hybridization. The discordance rates were correlated with the clinicopathologic characteristics, metastatic lesions, salvage treatment, and survival analysis in this population.

Results

A total of 142 (52.6%) MBC patients were diagnosed with discordant HR and HER2 status. Alterations in estrogen receptor (ER), progesterone receptor (PR), and HER2 status were observed in 20.70%, 37.78%, and 11.48% cases, respectively. Chemotherapy (P=0.0192) and endocrine therapy (P=0.048) significantly affected the conversion of HR status. Endocrine therapy was positively correlated with PR discordance (P=0.002), while ER discordance was associated with adjuvant chemotherapy (P=0.031). Survival analysis showed that ER status alterations between primary and metastatic lesions were associated with overall survival (P=0.002). The clinical prognosis was significantly worse with HR losses than with persistent HR positivity (P=0.023). In Cox multivariate analysis, the loss of HR expression and conversion to triple negative were independent prognostic indicators.

Conclusion

Discordance in HR status between primary and metastatic lesions may impact the prognosis of MBC, and HR conversion has independent prognostic value.

Clinical significance of evaluating hormone receptor and HER2 protein using cell block against metastatic breast cancer: a multi-institutional study

Hormone receptor and human epidermal growth factor receptor 2 (HER2) protein tests in metastatic breast cancer tissue are recommended in the guidelines of the American Society of Clinical Oncology/American Pathology Association. As part of a multi-institutional study by the National Hospital Organization, we conducted an investigation to examine these molecular markers, using cytological specimens as a substitute for tissue specimens from breast cancer metastasis. To confirm the usefulness of receptors tested in metastatic lesions, the treatment course of registered metastatic breast cancer patients was analyzed. During the April 2015 to March 2016 registration period, there were 62 registrations. Types of metastatic lesions include pleural fluid (44 samples), ascites (14 samples), lymph nodes (2 samples), pericardial fluid (1 sample), and dorsal subcutaneous mass (1 sample). A stable test result was obtained by adopting the receptor examination method, using cell block for immunostaining cytological specimens. The discordance rates of estrogen receptor (ER), progesterone receptor (PR), and HER2 protein expression were 18.2% (95% confidence interval (CI): 7.9–28.8%), 36.4% (95% CI: 23.7–49.1%), and 8.2% (95% CI: 0.1–16.3%), respectively, between the primary tumor and metastatic lesion. Patients who changed from primary negative to metastatic positive ER status had taken a significantly longer time for metastatic foci to appear. Patients with positive ER status in metastatic lesions had significantly better prognosis than ER-negative cases (P = 0.030) by the Log-Rank test. The ER status of the metastatic lesion and the metastatic site were independent prognostic factors by Cox multivariate analysis. Receptor examination with cytological specimens in metastatic lesions has been useful as it provides guidance for the treatment of metastatic breast cancer.

Prognostic value of receptor status conversion following neoadjuvant chemotherapy in breast cancer patients: a systematic review and meta-analysis

Biomarkers of breast cancer such as hormone receptors (HR) and human epidermal growth factor 2 (HER2) can be altered after neoadjuvant chemotherapy (NAC). However, whether the conversion of these receptors affects the prognosis of patients remains to be determined. We sought to evaluate the prognostic value of HR and HER2 receptors before and after NAC and to analyze their clinical implications. Relevant studies were used to calculate the pooled hazard ratios, 95% confidence interval (95% CI). This meta-analysis included eight studies with 2847 patients. Compared to patients with HR+ → +, patients with HR+ → - have shorter disease free survival (DFS) (hazard ratio = 2.64, 95% CI 1.86-3.75) and overall survival (OS) (hazard ratio = 2.99, 95% CI 1.97-4.54). Furthermore, patients with HR- → + tend to achieve better DFS (hazard ratio = 0.83, 95% CI 0.60-1.17) compared to patients with HR- → -. Patients with HR- → + gain better OS (hazard ratio = 0.67, 95% CI 0.46-0.99) compared to patients exhibiting HR- → -. When comparing patients with HER2+ → - to patients with HER2+ → +, patients with HER2+ → - tended to achieve better DFS (hazard ratio = 1.65, 95% CI 1.08-2.53) though results for OS (hazard ratio = 1.16, 95% CI 0.54-2.49) were not statistically significant. Our data strongly support the need for redetection of HR and HER2 receptor status of surgical sample following neoadjuvant therapy. Changes in HR status induced by NAC can be used as a prognostic factor in breast cancer patients for predicting both OS and DFS. HER2 change may also be valuable for predicting prognosis. Further research should explore therapeutic strategies for those presenting receptor status conversion.

Breast Carcinoma Metastasis to the Medial Rectus Muscle: Case Report

A 63-year-old woman with metastatic breast carcinoma presented to the ophthalmology clinic with diplopia and right abduction deficit. Magnetic resonance imaging showed isolated enlargement of the right medial rectus muscle. Biopsy of the enlarged muscle revealed metastasis of breast carcinoma. Ocular motility deficit in a patient with breast carcinoma should raise suspicion of metastasis to the orbit involving the extraocular muscles. Orbital imaging and biopsy are necessary for diagnosis and appropriate treatment.

Quadruple Negative Breast Cancers (QNBC) Demonstrate Subtype Consistency among Primary and Recurrent or Metastatic Breast Cancer

PURPOSE

Despite the availability of current standards of care treatments for triple negative breast cancer (TNBC), many patients still die from this disease. Quadruple negative tumors, which are TNBC tumors that lack androgen receptor (AR), represent a more aggressive subtype of TNBC; however, the molecular features are not well understood.

METHODS

Immunohistochemistry of estrogen receptor (ER), progesterone receptor (PR), HER2, and AR was determined in 244 primary and 630 recurrent/metastatic site biopsies. Expression was correlated with a panel of 25 cancer-related genes and proteins by IHC and in situ hybridization (ISH).

RESULTS

We observed that 80.2% (65 of 81) of primary TNBC tumors and 75.7% (159 of 210) of recurrent/metastatic TNBC tumors are QNBC. Bivariate fit analysis demonstrated that QNBC (n = 224) significantly (P < .03) correlated with younger aged patients at initial biopsy compared to AR positive TNBC patients (n = 51). In paired primary tissue samples and primary to recurrent/metastatic samples, at least 70% Luminal, HER2 enriched, and QNBC subtype did not change molecular profile. But, TNBC seems to be the "unstable" subtype. Within the total cohort, discordance in molecular profiles was identified in both synchronous (20%) and asynchronous (21%) intra-individual analyses. Irrespective of sample type, (Synchronous or Asynchronous), QNBC demonstrated higher concordant than TNBC. IHC and ISH results of the cancer related genes, demonstrated that gene/protein expression differ by molecular profile: TNBC (HR-/HER2-, AR+) and QNBC (HR-/HER2-, AR-). IHC in metastatic tumors, showed that the percentage of tumors positive of EGFR were higher, while PTEN and TLE3 were lower in QNBC compared to TNBC.

CONCLUSION

Standard treatment of Breast Cancer (BC) relies on reliable assessment by IHC analysis of ER, PR, and HER2. Our analyses suggest that the heterogeneity of TNBC is at least partially associated with the presence or absence of AR expression, suggesting that QNBC should be considered as a clinically relevant BC subtype. IHC analysis of AR appears to be a practical assay to determine the most aggressive TNBC subtypes and identifies tumors that could benefit from available targeted therapies.

[Role of biological heterogeneity in recurrent and metastatic breast cancer]

Breast cancer (BC) is a heterogeneous tumor, the biological characteristics of which vary with its growth and progression. Information on key tumor receptors (ER, PR, HER2, and Ki-67) is the basis for individualizing the diagnostic and treatment algorithm at all BC stages; however, the feasibility of biopsy of distant metastases and the re-testing of the biological subtype of BC in its suspected progression are being actively discussed in clinical practice. This review presents an update on the features of metastasis in different biological BC subtypes and assesses the clinical and prognostic role of biopsy of distant metastases in the lung, bones, liver, and brain. It shows the frequency of discordance in receptor status between primary and recurrent tumors at different sites of metastases, as well as the impact of changes in receptor status on survival rates in different biological BC subtypes. The relevance of performing biopsies in BC progression is shown to be beyond question, because it makes it possible to confirm the fact that the disease progresses, to re-test the biological subtype of recurrent BC, and to find new targets that allow the most effective drug treatment regimens to be used.

Prognostic significance of heparanase expression in primary and metastatic breast carcinoma

High levels of heparanase are detected in many types of tumors, associated with bad prognosis. Typically, heparanase levels are evaluated in a biopsy taken from the primary lesion, whereas its expression by the resulting metastases is most often unresolved. This becomes critically important as anti-heparanase compounds enter advanced clinical trials. Here, we examined the expression of heparanase in pairs of primary and the resulting distant metastases of breast carcinoma. Interestingly, we found that heparanase expression in the metastatic lesion does not always reflect its expression in the primary tumor. Accordingly, in some cases, the primary lesion was stained positive for heparanase while the metastasis stained negative, and vice versa. Heparanase discordance occurred in 38% of the patients, higher than that reported for hormone receptors, and was associated with bad prognosis. Thus, examination of heparanase levels in the tumor metastases should be evaluated for most efficient precision medicine applying heparanase inhibitors. Furthermore, we found that in stage I breast cancer patients strong heparanase staining is associated with shorter overall survival. Thus, heparanase levels can assist in the diagnosis and in determining the necessity and type of treatment in early stage breast cancer.