Outcome of breast cancer patients with low hormone receptor positivity: analysis of a 15-year population-based cohort

BACKGROUND

Guideline recommendations for the treatment of breast cancer with low hormone receptor (HR) expression (1%-9%) are ambiguous and several studies showed more similarities with HR-negative tumors than with HR strongly positive tumors (≥10%). We used a population-based 15-year cohort to compare patient characteristics and outcome of HR low positive tumors with HR-negative and HR strongly positive tumors, respectively.

PATIENTS AND METHODS

A total of 38  560 women diagnosed with early invasive breast cancer between 2004 and 2018 within the scope of the Munich Cancer Registry with 4.9 million inhabitants were included. Descriptive analyses of prognostic factors, treatment, and outcome analyses using the Kaplan-Meier method; cumulative incidence in consideration of competing risks; and multivariate analyses (Cox regression and Fine-Gray model) were conducted. Endpoints were time to local recurrence (TTLR), time to lymph node recurrence (TTLNR), time to metastasis (TTM), overall survival (OS), and relative survival (RS).

RESULTS

A total of 861 patients (2%) had HR low positive, 4862 (13%) HR-negative, and 32  837 (85%) HR strongly positive tumors. Within the HER2-negative cohort (n = 33  366), survival of HR low positive tumors was significantly worse than that of HR strongly positive tumors [OS hazard ratio 0.66 (95% confidence interval 0.55-0.78)], whereas between HR low positive and HR-negative tumors no significant survival difference could be detected [OS hazard ratio 0.93 (95% confidence interval 0.78-1.11)]. TTLR, TTLNR, and TTM showed similar results. By contrast, within the HER2-positive cohort (n = 5194), no statistically significant differences between the three HR groups could be detected in multivariate analyses.

CONCLUSION

Current definitions for HR positivity and its clinical relevance should be reconsidered. Patients with HR low positive/HER2-negative tumors could be regarded and treated similar to patients with triple-negative tumors.

Strong impact of MammaPrint and BluePrint on treatment decisions in luminal early breast cancer: results of the WSG-PRIMe study

PURPOSE

The WSG-PRIMe Study prospectively evaluated the impact of the 70-gene signature MammaPrint® (MP) and the 80-gene molecular subtyping assay BluePrint® on clinical therapy decisions in luminal early breast cancer.

METHODS

452 hormone receptor (HR)-positive and HER2-negative patients were recruited (N0, N1). Physicians provided initial therapy recommendations based on clinicopathological factors. After prospective risk classification by MammaPrint/BluePrint was revealed, post-test treatment recommendations and actual treatment were recorded. Decisional Conflict and anxiety were measured by questionnaires.

RESULTS

Post-test switch (in chemotherapy (CT) recommendation) occurred in 29.1% of cases. Overall, physician adherence to MP risk assessment was 92.3% for low-risk and 94.3% for high-risk MP scores. Adherence was remarkably high in "discordant" groups: 74.7% of physicians initially recommending CT switched to CT omission following low-risk MP scores; conversely, 88.9% of physicians initially recommending CT omission switched to CT recommendations following high-risk MP scores. Most patients (99.2%) recommended to forgo CT post-test and 21.3% of patients with post-test CT recommendations did not undergo CT; among MP low-risk patients with pre-test and post-test CT recommendations, 40% did not actually undergo CT. Luminal subtype assessment by BluePrint was discordant with IHC assessment in 34% of patients. Patients' State Anxiety scores improved significantly overall, particularly in MP low-risk patients. Trait Anxiety scores increased slightly in MP high risk and decreased slightly in MP low-risk patients.

CONCLUSIONS

MammaPrint and BluePrint test results strongly impacted physicians' therapy decisions in luminal EBC with up to three involved lymph nodes. The high adherence to genetically determined risk assessment represents a key prerequisite for achieving a personalized cost-effective approach to disease management of early breast cancer.

Abstract P1-01-03: Dynamics of circulating tumor cells during the course of chemotherapy and prognostic relevance across molecular subtypes in high-risk early breast cancer patients – Results from the adjuvant SUCCESS A trial

Background: The presence of circulating tumor cells (CTCs) before chemotherapy is known to be associated with reduced disease free survival (DFS) and overall survival (OS) in early breast cancer (EBC). In addition, recent findings suggest that CTCs persisting after adjuvant chemotherapy indicate poor prognosis. In an explorative analysis of the SUCCESS A trial, we evaluated the prognostic relevance of changes in CTC counts during the course of adjuvant chemotherapy across molecular subtypes to assess whether the prognostic role of persisting CTCs varies according to tumor biology.

Methods: The SUCCESS A trial is a phase III study, where patients with high-risk EBC (stage pN1-3 or pT2-4 or grade 3 or age ≤ 35 or hormone-receptor negative) were randomized to adjuvant chemotherapy with 3 cycles of epirubicin-fluorouracil-cyclophosphamide followed by either 3 cycles of docetaxel or 3 cycles of gemcitabine-docetaxel. CTC enumeration was performed before and after chemotherapy using the FDA-approved CellSearch® System (Janssen Diagnostics, LLC), and CTC positivity was defined as ≥ 1 CTC in 23 ml blood. Molecular subtypes were defined as luminal A like (hormone-receptor positive, grading 1 or 2), luminal B like (hormone-receptor positive, grading 3), triple-negative or HER2-positive. Patient outcome in terms of DFS and OS was analyzed using univariate log-rank tests and Cox regression models (median follow-up time 65.2 months).

Results: Data on both molecular subtypes and CTC status before and after chemotherapy were available for 1485 (39.6%) of 3754 patients randomized. This cohort contained 577 (38.9%) luminal A like, 236 (15.9%) luminal B like, 379 (25.5%) HER2-positive and 293 (19.7%) triple negative tumors. Overall, 917 (61.8%) patients were CTC negative before and after chemotherapy (neg/neg), 260 (17.5%) patients had a negative CTC status before and a positive CTC status after chemotherapy (neg/pos), 229 (15.4%) patients converted from positive to negative CTC status (pos/neg), and 79 (5.3%) patients were positive for CTCs at both time points (pos/pos). There were significant differences in DFS and OS among these four groups in patients with luminal A like tumors (log rank test, both p < 0.003) and patients with luminal B like tumors (log rank test, both p < 0.001). In both patients with luminal A like or luminal B like tumors, persistently CTC positive patients had the worst outcome (relative to persistently CTC-negative patients) in terms of DFS and OS. In contrast to luminal-like tumors, no significant differences with regard to DFS or OS were found among the four groups (neg/neg, neg/pos, pos/neg, pos/pos) in patients with HER2-positive or triple-negative tumors (log rank test, all p > 0.13).

Conclusion: The presence of CTCs both before and after adjuvant chemotherapy was associated with poor survival in luminal A like and luminal B like tumors, but not in HER2-positive or triple-negative tumors. Further research is needed to evaluate the effect of chemotherapy on CTC prevalence in different molecular subtypes of EBC.

Citation Format: Tzschaschel MLJ, Rack B, Andergassen U, Friedl TWP, Schneeweiss A, Mueller V, Tanja F, Pantel K, Gade J, Lorenz R, Rezai M, Tesch H, Soeling U, Polasik A, Alunni-Fabbroni M, Trapp EK, Mahner S, Schindlbeck C, Lichtenegger W, Beckmann MW, Fasching PA, Janni W. Dynamics of circulating tumor cells during the course of chemotherapy and prognostic relevance across molecular subtypes in high-risk early breast cancer patients – Results from the adjuvant SUCCESS A trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-01-03.

The West German Study Group Breast Cancer Intrinsic Subtype study: a prospective multicenter decision impact study utilizing the Prosigna assay for adjuvant treatment decision-making in estrogen-receptor-positive, HER2-negative early-stage breast cancer

PURPOSE

The West German Study Group (WSG) Breast Cancer Intrinsic Subtype (BCIST) study was designed to assess the influence of Prosigna gene signature assay results on physicians' adjuvant treatment recommendations by determining the extent of change in pre-test treatment recommendations following assay results. Secondary objectives were to assess the influence of Prosigna results on physicians' confidence in their therapeutic recommendations and on patients' decisional conflict status, anxiety levels, and functional status.

METHODS

This prospective, observational, decision impact study enrolled consecutive postmenopausal patients with estrogen-receptor (ER)-positive, HER2-negative, lymph-node-negative early-stage breast cancer in 11 centers in Germany. Physicians based their pre-test adjuvant treatment recommendations on standard clinico-pathological parameters. Tumor specimens were assayed using the Prosigna test in a WSG central pathology laboratory following manufacturer's guidelines. An independent pathology laboratory performed subsequent Prosigna assays on tumor sections to assess assay result concordance with the central laboratory. Physicians completed treatment confidence questionnaires prior to and after receiving Prosigna test results. Patients completed standardized questionnaires on decisional conflict, anxiety, and health status both before and after Prosigna testing.

RESULTS

The present study population consisted predominantly of low-to-intermediate risk patients (N = 198). Prosigna had 29.3% discordance in intrinsic subtyping with local immunohistochemistry test results. After Prosigna test results, a change in the adjuvant therapy recommendation occurred in 36 (18.2%) patients; 22 (11.1%) patients switched from no chemotherapy to chemotherapy. After Prosigna test results, physicians expressed increased confidence in their prognostic assessment in 87.9% of patients, and increased confidence in their treatment recommendation in 89.4%. Patients reported improved anxiety and emotional/functional well-being after receiving Prosigna test results.

CONCLUSIONS

Use of the Prosigna assay led to a change in 18.2% of adjuvant treatment decisions. Prosigna testing was associated with increased patient and physician confidence in treatment decisions, and with decreased patient anxiety and improved well-being. Any comparison of the therapeutic decision-making impacts of different genomic assays must account for potential confounding factors.

Detection and characterisation of disseminated tumour cells in bone marrow of breast cancer patients by immunostaining of Her-2 and MUC-1 in combination with Thomsen-Friedenreich (CD176)

Disseminated tumour cells (DTCs) in the bone marrow derive from many primary tumours, such as breast cancer. Their mere existence hints to present or future metastasis and implicates a worse prognosis for the patient. DTCs may possess different characteristics in comparison to the primary tumour due to events like Epithelial-Mesenchymal-Transition. Therefore, these cells might be able to survive chemotherapy and cause relapses of the disease at a later point. We aimed to detect and further characterise DTCs by an immunostaining approach with three different antigen markers (Her-2, MUC-1 and TF, also known as CD 176). For that reason, bone marrow of 41 breast cancer patients was obtained during surgery; DTCs were enriched by density gradient centrifugation and cytospins were prepared. After fixation, immunofluorescent double-stainings were carried out with antibodies against CD176 in combination with HER-2 or MUC-1. Cells co-expressing two antigens were found in all staining combinations (Her-2 and CD176: 46.14%; MUC-1 and CD176: 18.15% of all cases). Cells that stained for a single antigen only were also found (Her-2: 36.86%; MUC-1: 34.45%; CD176: 29.65% of all cases). Significant correlations between the stainings of all markers could be shown (p<0,001). In conclusion, Thomsen-Friedenreich Antigen (TF, CD176) is a promising marker in combination with the established marker Her-2 and other markers like MUC-1. These results may serve as a basis for future DTC detection routines and help to individualize medical treatment, reducing side effects and increasing the efficiency of the therapy.

Participation in the SUCCESS-A Trial Improves Intensity and Quality of Care for Patients with Primary Breast Cancer

The SUCCESS-A trial is a prospective, multicenter, phase III clinical trial for high-risk primary breast cancer. It compares disease-free survival after randomization in patients treated with fluorouracil, epirubicin and cyclophosphamide followed by 3 cycles of docetaxel (FEC-D) with that of patients treated with 3 cycles of FEC followed by 3 cycles of gemcitabine and docetaxel (FEC-DG). After a second randomization patients were treated with zoledronate for 2 or 5 years. A total of 251 centers took part in the trial and 3754 patients were recruited over a period of 18 months which ended in March 2007. In a questionnaire-based survey we investigated the impact of enrollment in the trial on patient care, the choice of chemotherapy protocol and access to current oncologic information as well as overall satisfaction in the respective centers. Analysis of the 78 questionnaires returned showed that 40 % of the centers had never previously enrolled patients with these indications in clinical studies. Prior to participating in the study, 4 % of the centers prescribed CMF or other protocols in patients with high-primary breast cancer risk, 46 % administered anthracycline-based chemotherapy and 50 % gave taxane-based chemotherapy. Around half of the participating centers noted that intensity of care and overall quality of care became even better and that access to breast cancer-specific information improved through participation in the trial. After their experience with the SUCCESS-A trial, all of the centers stated that they were prepared to enroll patients in clinical phase III trials again in the future. These data indicate that both patients and physicians benefit from clinical trials, as enrollment improves treatment strategies and individual patient care, irrespective of study endpoints.

Abstract P2-01-11: Detection and characterization of circulating and disseminated tumour cells in blood and bone marrow of breast cancer patients by two different biochemical methods

Background: The main reason for breast cancer associated death are remote metastases, that are due to cells, that dissolve from the primary tumour, and are found in blood (circulating tumour cells, CTCs) and bone marrow (disseminated tumour cells, DTCs). The detection of these cells in breast cancer patients is mostly linked to a worse prognosis.

We present an immunohistochemical staining method for the detection of DTCs from bone marrow by using the cancer-associated Thomsen-Friedenreich antigen (TF) in combination with Her-2, and stem cell markers (Muc-1, ALDH1A1), and a highly sensitive RT-PCR based approach for CTC-detection from peripheral blood of adjuvant breast cancer patients using the established cytokeratin markers CK8, 18 and 19.

Materials and Methods: 20ml blood and 2–3ml of bone marrow were withdrawn from 20 respectively 40 primary breast cancer patients during surgery. For this investigation we used only samples of patients with at least one CTC already detected with the FDA approved VERIDEX CellSearch System.

RT PCR investigations blood samples from healthy donors were taken and used as control group.

For both methods an enrichment of mononuclear cell fraction, containing DTCs and CTCs, was carried out by density gradient centrifugation.

For immunohistochemical staining cells were spun down on coverslips fixed and stained with antibodies against Thomsen-Friedenreich-Antigen and Her-2, MUC1 or ALDH1A1.

For Real-Time PCR RNA was isolated from the cell pellet obtained by density gradient centrifugation, reversely transcribed to cDNA and RT-PCR was run with Taq-Man Primers against Cytokeratin (CK) 8, 18 and 19. The housekeeping gene 18S was used as internal reference.

Results: For the staining of Her-2 and TF, 78,01% of all samples showed at least one stained cell. The biggest subgroup within these samples was the double stained one with 46,14%.

In the other two experimental settings respectively the biggest cohorts were only single stained with TF (47,4% for TF-MUC1) or ALDH1A1 (59,65% for TF-ALDH1A1).

Within the PCR trials, the investigation between the negative control group and adjuvant breast cancer blood samples showed significant correlations for the expressions of CK8 (p &lt; 0,047) and CK18 (p &lt; 0,041). CK19 showed borderline significance (P &lt; 0,057) of correlation.

Conclusion: The immunostaining-combination of diverse cell surface antigens for detection and characterization of DTCs, especially the TF antigen, in combination with Her-2, Muc-1 and ALDH1A1 is an excellent way to detect DTC's in bone marrow due to its significant correlations (p &lt; 0.001).

The verification of CTC's by using RT-PCR is possible by using epithelial marker genes like the cytokeratins, especially CK8 and 18.

Both methods can be a step towards modern personalized medicine and lead to new ways of early tumour detection. Additionally an improved tumour characterization might ease the decision on specific medical treatment (eg against Her-2).

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-01-11.

Expression of cathepsin-D in primary breast cancer and corresponding local recurrence or metastasis: an immunohistochemical study

BACKGROUND/AIM

The role of cathepsin-D is well established in breast cancer progression, being correlated with worse clinical outcomes. However, to our knowledge, no study has been performed investigating its expression in primary breast cancer tumors and their corresponding recurrences or metastasis.

MATERIALS AND METHODS

Tissue sections from ten breast cancer cases and their corresponding local recurrences and six breast cancer cases and their corresponding metastases were immunohistochemically assessed for cathepsin-D reactivity. Cases diagnosed as either ductal carcinoma in situ (n=7), or breast carcinoma with no evidence of local recurrence or metastasis during follow-up (n=8) served as controls.

RESULTS

Cathepsin-D was significantly up-regulated in all the study groups compared to controls. No difference was found between primary tumors and their corresponding recurrences or metastases.

CONCLUSION

Cathepsin-D-expressing breast cancer cells seem to be involved in local recurrence or metastasis formation. Large series are needed to further verify this result with the aim of possible future molecular intervention.

P1-07-24: Quantitative and Immunohistochemical Detection of Breast Cancer Cells in Blood Samples

Background Disseminated tumor cells (DTCs) in bone marrow and circulating tumor cells (CTCs) in blood are found in patients with epithelial carcinomas (breast cancer) and are often correlated with poor prognosis of the disease. In current models circulating tumor cells (CTCs) dissolved from the primary tumor are thought to be responsible for the occurrence of metastases. However, the detection of CTCs is still a technical challenge. In this study, two methods for tumor cell detection of patients’ samples are presented (Real-Time-PCR and immunohisto-chemical staining). Both are simple and known methods with a high sensitivity and a spread marker panel.

Materials and Methods For the implementation of both methods, different breast cancer cell lines have been used (Cama-1, MCF-7; ZR-75-1). For Real-Time-PCR, blood samples of a healthy donors were spiked with different cell counts (0, 10, 100, 1000, 10.000 and 100.000) per ml blood sample. Total RNA was isolated from the samples, reversely transcribed into cDNA and used for TaqMan Real-Time-PCR reaction with probes against CK8, 18 and 19, while 18S was used as reference. Relative Quantification Curves were drawn by Microsoft™ Excel®. For immunohistochemical staining, cytospins were prepared from spiked blood samples, fixed with acetone, air dried and stained with antibodies against Her2- and Thomsen-Friedenreich-Antigen (CD176). In a second staining step fluorescently labelled secondary antibodies were applied. Nuclei were counterstained with DAPI, TF-Antigen was stained by Cy2 and Her2-Antigen by Cy3. The staining was controlled and documented by an epifluorescence microscope.

Results The curve of Relative Quantification for MCF-7 and ZR-75-1 cells shows an increasing slope starting from 1000 cells. For the Cama-1 cell line this trend is already seen from 10–100 cells. In ZR-75-1 all three genes analysed reveal this trend, whereas in Cama-1 and MCF-7 cells a strong increase in Relative Quantification is especially seen for CK8 and 18. In the immunohistochemical staining, the cells were considered as tumour cells if they showed staining with the antibody-combinations used. Stained cells were counted and recovery rates were determined. For ZR-75-1, 17 of 30 cells which were spiked in the blood samples were recovered. For MCF-7, 18 cells were found in average, and for Cama-1 23 cells were located per slide. The recovery rates calculated from these numbers are 56,6% and 60,0% for ZR-75-1 and MCF-7, for Cama-1 the recovery rate reaches 76,6%.

Conclusion It seems that Cama-1 cells are a better model than MCF-7 and ZR-75-1 for Real-Time PCR quantification of mamma carcinoma tumor cells in blood samples. MCF-7 and ZR-75-1 cells tend to react more likely immunologically with blood cells of the donor (agglutination between blood cells and cancer cells). The Cama-1 cell line shows also advantages in the detection of tumor cells using immunohistochemical staining. Therefore it will be necessary to test both methods on patient samples to proof their benefit.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-07-24.

Prognostic relevance of disseminated tumor cells in the bone marrow of patients with primary breast cancer--results of a standardized follow-up

BACKGROUND

The prognostic significance of disseminated tumor cells from bone marrow (BM-DTCs) of breast cancer patients has been demonstrated previously. In this study, data of a standardized long term follow-up of 829 patients with examination of BM-DTCs at primary diagnosis are presented.

PATIENTS AND METHODS

BM aspiration and immunocytochemical examination of DTCs was performed according to a standardized protocol. Follow-up data of all patients were adjusted with the cancer registries of southern Bavaria.

RESULTS

A total of 268 patients (32%) had BM-DTCs with a median of 2 (1-1223)/2 x 10⁶ cells. Positive BM findings correlated with tumor size (p=0.032), but not with other histopathological parameters. After a median follow-up of 73 months, BM-DTCs were highly relevant for the development of distant metastases (p=0.006) and, beneath standard histological parameters, reduced overall survival (p=0.038).

CONCLUSION

These results confirm the prognostic relevance of the detection of BM-DTCs. Newer methods, such as detection of circulating tumor cells in blood, will have to demonstrate comparable prognostic information in the future.

Abstract P3-10-20: The Prognostic Relevance of Serum CA27.29 level in Primary Breast Cancer Patients before Adjuvant Chemotherapy — Results of the German SUCCESS Trial

Background: While tumor markers are frequently used to assess treatment efficacy in metastatic breast cancer, there is lack of evidence regarding the role of MUC-1 markers in primary disease. The value of CA27.29 in the adjuvant setting was prospectively evaluated in the German multicenter SUCCESS study.

Material and Methods: The German SUCCESS trial is a multicenter phase III study comparing FEC-Docetaxel (Doc) vs. FEC-Docetaxel-Gemcitabine (Doc-G) and 5 versus 2 years of Zoledronate as adjuvant treatment in patients with node positive or high risk node negative primary breast cancer. In this trial serum CA27.29 level has been prospectively evaluated in 3202 patients before and immediately after adjuvant chemotherapy as well as 2 and 5 years thereafter. CA27.29 was measured with the ST AIA-PACK CA27.29 reagent using MUC-1 for AIA-600II (Tosoh Bioscience, Tessenderlo, Belgium). The cutoff for positivity was &gt;31 U/ml. Results: Mean CA27.29 serum level before adjuvant chemotherapy was 19,3 U/ml (SD +/− 15,5) in both arms. 8,0% (n=127) of patients in the FEC-Doc-G arm and 7,4% (n= 120) in the FEC-Doc arm had marker levels of more than 31 U/ml. Mean CA27.29 serum levels were significantly higher in patients with lobular carcinoma (p=0.001), with positive lymph nodes (p=0.02) and post-menopausal patients (P&lt;0.001). After a median follow-up period of 34 months 233 patients relapsed and 108 patients died. CA27.29 before chemotherapy was a significant prognostic marker for disease-free survival (DFS) (P&lt;0.0001) and overall survival (OAS) (P&lt;0.0001) in univariate and multivariate analysis. Conclusion: These findings indicate the independent prognostic relevance of serum CA27.29 levels in primary breast cancer patients before adjuvant treatment. Further follow-up within the SUCCESS trial will show whether initial CA27.29 level could serve as a tool for adjuvant treatment monitoring.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-10-20.

Inhibin A is down-regulated during chemotherapy in patients with breast cancer

BACKGROUND

Inhibins are dimeric glycoproteins, composed of an alpha-subunit (INH-α) and one of two possible beta-subunits (βA or βB), with substantial roles in human reproduction and in endocrine-responsive tumours. Aims of this study were to determine the serological measurement of inhibin A (α-βA) in breast cancer patients during chemotherapy.

PATIENTS AND METHODS

A series of 30 breast cancer patients who underwent standardised chemotherapy were prospectively evaluated before chemotherapeutic treatment as well as four weeks after chemotherapy and two years after chemotherapy for the serological expression of inhibin A. For statistical analysis the Wilcoxon rank sum test was used for paired samples. Statistical significance was assumed at p<0.05.

RESULTS

The concentration of inhibin A showed a significant decrease between data obtained before chemotherapy and after chemotherapy (p<0.005) and two-year follow-up (p<0.001). Interestingly, there were no differences in inhibin A concentrations between the four-week and two-year follow-up (p=0.744).

DISCUSSION

Chemotherapy significantly decreases inhibin A concentration during chemotherapy. This might reflect a suppression of ovarian function, being also a marker for chemotherapy-induced amenorrhoea. Moreover, it has been suggested that inhibin A might be a tumour marker for breast cancer, and therefore a sudden increase in its concentration might be indicative of breast cancer recurrence.

Perioperative search for circulating tumor cells in patients undergoing radical cystectomy for bladder cancer

Objective

Despite having an organ confined tumor stage at the time of radical cystectomy, a certain number of bladder cancer patients will develop local or distant metastases over time. Currently there are no reliable serum markers for monitoring and evaluating risk profiles of urothelial cancers. Several studies suggest that detection of Circulating Tumor Cells (CTC) may correlate with disease status and prognosis at baseline and early in the treatment of cancers. The presence of CTCs in whole blood before and during radical cystectomy could provide further information on disease status, and could be used as an indicator to determine the need for adjuvant or even perioperative chemotherapy.

Methods

From 03/2009 to 05/2009, five patients with histologically proven transitional cell carcinoma of the urinary bladder participated in this study. All patients were admitted to the hospital for radical cystectomy (rCx). A standard or extended lymph node dissection was performed in all cases. Preoperative CT or MRI scans revealed no distant or local metastases. Median age was 66.8 years (55-81 yrs). After obtaining informed consent from each patient, approximately 30 mL of peripheral blood was taken immediately before rCx and again during surgical removal of the urinary bladder from the patients' body. As additional parameters, operation time (OR) for surgical removal of the bladder and the amount of blood volume that was used for the detection of CTCs were recorded. Obtained blood samples were processed using the Cell-Search System (Veridex^©) within 48 hours of collection. CTCs were identified and quantitated using the Cell-Search System, followed by re-evaluation of the provided results by specially trained and experienced personal. (CS, SH)

Results

CTCs were detected before and during surgical removal of the urinary bladder in one of five patients (20%). In the one patient positive for CTC, two CTCs were detected in the blood sample that was obtained before surgery (analyzed blood volume was 25 mL). There was one CTC detected in the blood sample that was obtained during surgical removal of the urinary bladder (analyzed blood volume was 27 mL). There was no rise in the amount of CTCs during surgical procedure. The final pathological report of this patient showed an advanced tumor stage (T3b, N0, R1). In the other patients, no CTCs were detected at all, neither before rCX nor right after surgical removal of the bladder. Pathological stage for these patients ranged from pT1m G3 -pT2b G3. None of these patients showed lymph node involvement. An average of 14.6 lymph nodes (5-40 LNs) were obtained. OR time to surgical removal of the urinary bladder ranged from 60 minutes to 150 minutes (mean 82 min.).

Conclusions

Although only a very small group of patients was analyzed in this study, the presence of CTCs seems to be correlated with an advanced tumor stage. Therefore the detection of CTCs could be used for an optimized assessment of a patient's disease status in urothelial cancer. A further aim of this study was to assess whether surgical manipulation during radical cystectomy is associated with a release of CTCs into the vascular system. None of the patients who were negative for CTCs before surgery showed CTCs during surgical removal of the bladder, suggesting that there was no release of CTCs during surgery. However, further study is needed to prove these findings and evaluate the significance of CTCs as an indicator for therapeutic decisions.

Inhibin A Is Downregulated during Chemotherapy in Patients with Early Breast Cancer

Introduction: Inhibins are dimeric glycoproteins, composed of an alpha-subunit (INH-a) and one of two possible beta-subunits (ßA or ßB), with substantial roles in human reproduction and in endocrine-responsive tumours. In breast cancer tissue, the growth factor Inhibin A is involved in cell differentiation and proliferation, thus suggesting a possible role as tumor marker. Aims of this study were to determine the serological measurement of Inhibin A (a- bA) in breast cancer patients during chemotherapy.Material and Methods: A series of 28 high risk N0 and N+ breast cancer patients who underwent standardized chemotherapy (3 x FEC and 3 x Docetaxel) followed by two years of zoledronate in the German SUCCESS trial were prospectively evaluated before chemotherapeutic treatment as well as after chemotherapy and two years after chemotherapy for the serological expression of Inhibin A. For serological analysis the ultrasensitive Inhibin A ELISA (DSL – U.S.A.) was used according to manufactures instruction. For statistical analysis the Wilcoxon rang sum test was used for paired samples. Statistical significance was assumed at p&lt; 0.05.Results: The concentration of Inhibin A showed a significant decrease between data obtained before chemotherapy and after chemotherapy (p&lt;0.005) and two-year follow up (p&lt;0.001). Interestingly, there were seen no differences between the time point four weeks after chemoherapy and at two years (p=0.744).Discussion: Therefore, chemotherapy decreases significantly the Inhibin A concentration during chemotherapy. This might reflect a suppression of ovarian function and might be a marker for chemotherapy-induced amenorrhoea. Moreover, it has been suggested that Inhibin A might be a tumour marker for breast cancer, and therefore a sudden increase of its concentration might be indicative of breast cancer recurrence.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3028.

Evaluation of CA 27.29 as Prognostic Marker in Primary Breast Cancer Patients – Results of the German SUCCESS Trial

Background:While tumor markers are frequently used for the evaluation of treatment efficacy in metastatic breast cancer, the role of Muc-1 markers in primary disease and during recurrence-free follow-up is still under discussion. In the German multicenter SUCCESS trial we evaluated CA 27.29 in 3754 patients before and after adjuvant chemotherapy and 2 and 5 years after primary diagnosis.Methods:The SUCCESS Trial compares FEC-Docetaxel (Doc) vs. FEC-Doc-Gemcitabine (Doc-G) regime and two vs. five year treatment with Zoledronat in patients with primary breast cancer (N+ or high risk N-). CA27.29 has been measured with ST AIA-PACK CA27.29 reagent using MUC-1 for AIA-600II (Tosoh Bioscience, Tessenderlo, Belgium). The cutoff for positivity of CA27.29 is &gt;31 U/ml.Results:In 2807 primary breast cancer patients CA27.29 has been prospectively evaluated before and after chemotherapy. 22% of all patients had a marker &gt;31 U/ml (n=587, mean 19.00, range 3.04-410) before and 39% (n=1058, mean 23.34, range 2.70-330) after chemotherapy.After a median follow-up period of 18 months 138 patients developed a recurrence of their disease. 12% (n=17) of patients with recurrent disease had before chemotherapy a marker &gt;31 U/ml (mean 28.08, range 4.95-410). After completion of chemotherapy 16% of patients (n=22) had a CA 27.29 marker &gt;31 U/ml (mean 21.7, range 5.35-330).7% (n=10) had shown positivity of CA27.29 before and after therapy. 5% (n=07) of patients changed from positive to negative (cutoff for CA27.29) afterwards. 80% (n=109) were negative before and after therapy, whereas 8% (n=12) became positive after treatment.There is no significant difference in positivity of CA27.29 between Patients with an onset of disease recurrence in the first year (n=38), second year (n=68), the third year (n=24) after chemotherapy and all other prospectively evaluated patients with primary breast cancer (n=2784).Before chemotherapy treatment the prevalence of elevated CA27.29 in all 2807 primary breast cancer patients was equally distributed between the FEC-Doc and the FEC-Doc-G arm. After chemotherapy 34% in the FEC-Doc arm showed an increased level vs. 45% in the FEC-Doc-G arm. The correlation analysis showed no significant coherence between hormonal status (ER: p&lt;0.323; PR: p&lt;0.078), HER2/neu status (p&lt;0.308), Grading (p&lt;0.565) and CA27.29 level. Tumor size (p&lt;0.020) and the nodal status (p&lt;0.022) were significant associated with Ca27.29 levels.Conclusion:This marker will be useful for treatment monitoring; first of all because a close relation between Ca27.29 and tumor mass at primary diagnosis is evident. But only further results of the SUCCESS-trial, especially the evaluation of CA27.29 blood level at follow-up examination 2 years and 5 years after chemotherapy, will improve the prognostic relevance of this marker.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3023.

Detect-Study: Comparison of Two Techniques for the Evaluation of the HER2 Expression on Circulating Tumor Cells in Metastatic Breast Cancer

Introduction:There is a growing body of evidence that the HER2 status can change during disease progression (Gancberg et al. 2003). However, the re-assessment of the HER2 status to evaluate the eligibility for HER2 targeted therapy by a tissue biopsy of the metastatic lesion may not always be feasible. In this context, determination of the HER2 status using CTCs might be a strategy with potential clinical application. So far, no large prospective studies were performed comparing different methods for CTCs detection and characterization. The aim of this trial was to determine the HER2 status of CTCs in metastatic breast cancer patients using the antibody based CellSearch©assay and the RT-PCR approach AdnaTest Breast Cancer and to assess the concordance rate between these two techniques. Both techniques are frequently used in clinical trials.Method:A total of 252 metastatic breast cancer patients from 9 different certified breast cancer centers (Düsseldorf, Erlangen, Essen, Freiburg, Hamburg, Heidelberg, Muenchen, Regensburg, Tuebingen) were enrolled in this prospective open trial from 01/2008 until 04/2009. HER2 status of CTCs was assessed using both the FDA approved CellSearch©Assay (Veridex, Warren, NJ, USA) and the AdnaTest Breast Cancer (Adnagen, Langenhagen, Germany) according to the manufacturers' instructions. A web based databank was designed for data management and online-documentation (www. detect-study.de). The study design was approved by the ethics' comittee (2007/B01).Results:Using the CellSearch©Assay, 133 of 252 (55%) metastatic patients had CTCs at the time of first diagnosis or disease progression. HER2 positivity was observed in 39% of CTC positive patients (52 of 133) but only 22 of these had initially a HER2 positive primary tumor. Eighty-eight of 225 (39%) patients were CTC positive using the AdnaTest Breast Cancer. The HER2 positivity rate was 47% (41 of 88). Eight of these patients had a HER2 positive primary tumor whereas 33 patients were initially HER2 negative or unknown. Summarizing the data, the rate of breast cancer patients with HER2 negative primary tumors but HER2 positive circulating tumor cells was 38% (32 of 61) and 48% (28 of 41) using the CellSearch Assay and the AdnaTest Breast Cancer, respectively. Considering only those patients who had CTCs on both tests (n=61), the concordance rate regarding HER2 expression was 51% (32 of 61).Conclusion:Based on CTCs the HER2 status can change during disease progression. However, using different techniques, disconcordant results were obtained. To prove the clinical value of these CTC assays and to implement the HER2 status of CTCs as a stratification parameter in future clinical trials, it will be mandatory to correlate clinical response to HER2 targetd therapy on each method in patients with HER2 positive CTCs.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3004.

Persistance of circulating tumor cells (CTCs) in peripheral blood of breast cancer (BC) patients two years after primary diagnosis

554

Background: In metastatic BC, CTCs have shown to predict treatment efficacy and reduced survival. Recent data also indicate a potential prognostic relevance of CTCs after adjuvant chemotherapy. The SUCCESS trial evaluates the role of persisting CTCs two years after diagnosis in primary BC patients treated with zoledronate. Methods: We analyzed 23 mL of peripheral blood in N+ and high-risk N- primary BC pts receiving 3xFEC(500/100/500)-3xDoc100 q3w vs. 3xFEC(500/100/500)-3xDocgemcitabine (75/1000 d1+8) chemotherapy followed by 2 yrs (4mg q3mx24m) vs. 5 yrs (4mg q3mx24m followed by q6mx36m) of zoledronate. CTC results after two years are shown. CTCs were assessed with the CellSearchSystem (Veridex, Warren, USA). After immunomagnetic enrichment with an anti-Epcam-antibody, cells were labelled with anti-cytokeratin (8,18,19) and anti-CD45 antibodies. Pts were examined after a mean of 29 months (range 20–43). Results: The data of 579 pts two years after diagnosis are available. 4.3% of pts (n = 25) presented with >1CTC in peripheral blood. In pts with the detection of CTCs, the mean number of cells was 1 (range 1–29). While we found 1 CTC in 5.9% and 2 CTCs in 1.6% of pts, 1.5% had 3–5 CTCs, 1.2% >5 CTCs. The presence of >1CTC did not correlate with tumor size (p = 0.41), nodal status (p = 0.41), grading (p = 0.45), hormonal status (p = 0.92) or HER-2-Status of the tumor (p = 0.59). In this patient group, 9.7% and 6.9% of pts had presented with >1CTC at primary diagnosis and after chemotherapy, respectively. While the presence of CTCs at diagnosis was associated with CTCs after two years (p = 0.03), there was no correlation of CTCs after chemotherapy with the results at primary diagnosis (p = 0.08) or at two years (p = 0.23). In 184 postmenopausal HR+ pts endocrine treatment data was analyzed. CTCs at two years were detected in 6.8% of pts on tamoxifen (n = 9), while 1.9% of pts were positive on anastrozole treatment (n = 1; p = 0.19). Conclusions: CTCs persisting cytostatic, endocrine and zoledronate treatment, can be observed in a relevant number of clinically recurrence-free BC patients. Longer follow-up within the German SUCCESS study will give further insight in their prognostic relevance and show whether they can be used for real time tumor phenotyping or serve as treatment target.

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Minimal residual disease detection in peripheral blood of primary breast cancer patients – translational research in the SUCCESS-study

Abstract #5019

Background: The detection of occult tumor cells in the bone marrow of patients with breast cancer has been shown to be an independent predictive and prognostic factor for early disease recurrence and decreased overall survival. However, it is more feasible to monitor treatment efficacy by sampling peripheral blood. The translational research program of the German SUCCESS-trial evaluates Minimal Residual Disease (MRD) in peripheral blood during adjuvant treatment of breast cancer patients. Follow-up results of the detection of MRD at primary diagnosis and after adjuvant chemotherapy (CT) are presented.&#x2028; Patients and Methods: Cells were separated by Oncoquick® (Greiner-bio one, Frickenhausen, Germany) followed by labeling of epithelial cells with an anti-cytokeratine-antibody (directed against cytokeratins 8, 18 and 19) and immunocytochemical staining. Every preparation was screened by two independent persons. MRD was defined as one or more cytokeratine-positive cell.&#x2028; Results: 1237 breast cancer patients were analyzed at primary diagnosis. After completion of adjuvant CT 655 patients returned for a second blood sampling. The majority of the tumors was small (40.1% pT1, 52.7% pT2, 5.9% pT3, 1.1% pT4) but mostly of intermediate or unfavorable grade, (G1 4.6%, G2 48.9%, G3 46.2%). 65% of the patients were node-positive (35% pN0, 45.6% pN1, 13.8% pN2, 5.7% pN3) and a positive hormone receptor status was seen in 69.1%. In 25.4% the Her2 status was positive. In 20.3% of all patients MRD was found at primary diagnosis. After CT MRD was observed in 15,7%. The mean number of detected cells was 2.3 (range: 1-25) before and 2.1 (range 1-23) after chemotherapy. Neither tumor size (p=0.48, p=0.47), lymph node metastases (p=0.34, p=0.81), histopathological grading (p=0.83, p=0.85) nor hormone receptor status (p=0.72, p=0.65) of the primary tumor correlated with the presence of MRD before or after CT respectively. The Her2/neu status of the primary tumor did not correlate before, but after CT with the presence of the MRD (p=0.63, p=0.08).&#x2028; Conclusion: The detection of MRD in peripheral blood can be widely used and is suitable for repeated measurements. Further follow-up of the SUCCESS trial will show this method´s validity for risk stratification and monitoring of treatment efficacy in breast cancer patients.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5019.