Heterogeneity of HER2 Expression in Circulating Tumor Cells of Patients with Breast Cancer Brain Metastases and Impact on Brain Disease Control

Simple Summary

Results from a previous study suggested that the number of circulating tumor cells (CTC) might have a role as a biomarker of early distant brain failure in patients with breast cancer brain metastases (BCBM). However, it remains largely underexplored whether heterogeneous HER2 expression in CTC may have a prognostic implication. We evaluated the status of HER2 expression in CTC before and after radiotherapy/radiosurgery for BCBM and observed that the presence of HER2 expression in any moment was associated with longer distant brain failure-free survival, irrespective of the primary immunophenotype of the breast tumor. This finding suggests that the status of HER2 expression in CTC has the potential to improve the treatment selection for patients with BCBM.

Abstract

HER2 expression switching in circulating tumor cells (CTC) in breast cancer is dynamic and may have prognostic and predictive clinical implications. In this study, we evaluated the association between the expression of HER2 in the CTC of patients with breast cancer brain metastases (BCBM) and brain disease control. An exploratory analysis of a prospective assessment of CTC before (CTC1) and after (CTC2) stereotactic radiotherapy/radiosurgery (SRT) for BCBM in 39 women was performed. Distant brain failure-free survival (DBFFS), the primary endpoint, and overall survival (OS) were estimated. After a median follow-up of 16.6 months, there were 15 patients with distant brain failure and 16 deaths. The median DBFFS and OS were 15.3 and 19.5 months, respectively. The median DBFFS was 10 months in patients without HER2 expressed in CTC and was not reached in patients with HER2 in CTC (p = 0.012). The median OS was 17 months in patients without HER2 in CTC and was not reached in patients with HER2 in CTC (p = 0.104). On the multivariate analysis, DBFFS was superior in patients who were primary immunophenotype (PIP) HER2-positive (HR 0.128, 95% CI 0.025–0.534; p = 0.013). The expression of HER2 in CTC was associated with a longer DBFFS, and the switching of HER2 expression between the PIP and CTC may have an impact on prognosis and treatment selection for BCBM.

MIR-203A-3P AND MMP-2 PROTEINS ARE HIGHLY EXPRESSED IN CIRCULATING TUMOR CELLS FROM PATIENTS WITH PANCREATIC CARCINOMA

OBJECTIVES

Ductal adenocarcinoma of the pancreas is the fourth most common cancer-associated cause of death in the Western world. The presence of circulating tumor cells (CTCs) can be considered a potential prognostic factor, as these cells represent tumor progression, allowing monitoring of therapeutic efficacy. The objectives of this study were to explore the morphological, molecular, and phenotypic characteristics of CTCs from the blood of patients with pancreatic carcinoma and to correlate the findings with response to treatment, progression-free survival, overall survival (OS), and deep vein thrombosis (DVT).

METHODS

Peripheral blood (10 mL) was analyzed before the beginning of treatment after 60 and 120 days. CTCs were detected by using ISET® and characterized by immunocytochemistry. For microRNAs (miRNAs) analysis, peripheral leukocytes from the same patients and healthy individuals (controls) were collected in parallel at baseline. The expression of miRNAs was evaluated (in pool) using TaqMan® Array Human MicroRNA Cards v2.0.

RESULTS

Only nine patients were included. The proteins, namely, matrix metalloproteinase-2 (MMP2) and TGFβ-RI, were highly expressed (77.7%) in CTCs at baseline; at the first follow-up, MMP2 was predominant (80%) and, at the second follow-up, MMP2 and vimentin were predominant (50%). Circulating tumor microemboli (CTMs) were found in two patients and both presented DVT. The miR-203a-3p was highly expressed in CTCs. The miR-203a-3p is involved in the stimulation of epithelial-to-mesenchymal transition (EMT) and is related to worse OS in pancreatic cancer (TCGA data).

CONCLUSION

Due to the low number of patients and short follow-up, we did not observe a correlation between CTCs and response to treatment. However, there was a correlation between CTM and DVT and also miR-203a-3p was highly expressed in CTCs, corroborating the findings of EMT proteins. This study opens the perspectives concerning the dynamic change in the pattern of proteins expressed along with treatment and the use of miRNAs as new targets in pancreatic carcinoma.

Prognostic impact and potential predictive role of baseline circulating tumor cells in locally advanced head and neck squamous cell carcinoma

OBJECTIVES

The prognostic impact of circulating tumor cells (CTCs) or circulating tumor microemboli (CTM) in locally advanced head and neck squamous cell carcinoma (LA-HNSCC) is yet to be determined, with conflicting results in previous trials. The role of induction chemotherapy (ICT) in the management of LA-HNSCC is controversial with no predictive biomarkers to guide treatment strategy in this scenario. The aim of this trial is to determine the prognostic impact of CTCs and CTM, their biomarkers expression by immunocytochemistry (ICC), and its potential role as predictors of ICT benefit in LA-HNSCC.

MATERIALS AND METHODS

Prospective study, with newly diagnosed stage III/IV non-metastatic LA-HNSCC patients treated with curative intent. Blood samples analyzed for CTCs and CTM before treatment using the ISET method.

RESULTS

A total of 83 patients were included. CTCs counts were an independent prognostic factor for overall survival (OS; HR: 1.17; 95 %CI: 1.05-1.31; p = 0.005) and progression free survival (PFS; HR:1.14; 95 %CI: 1.03-1.26; p = 0.007). Using the Lausen and Schumacher technique, 2.8 CTCs/mL for OS and 3.8 CTCs/mL for PFS were defined as the best cut-offs. CTM were detected in 27.7% of patients, correlating with worse PFS (HR = 2.70; IC95%: 1.30-5.58; p = 0.007). MRP-7 expression in CTM correlated with worse OS (HR = 3.49; 95 %CI: 1.01-12.04; p = 0.047) and PFS (HR = 3.62; 95 %CI: 1.08-12.13; p = 0.037). CTCs counts were predictive of complete response to treatment (OR = 0.74; 95 %CI: 0.58-0.95; p = 0.022) and high counts (cut-off 3.8/mL) and CTM were potential predictors of ICT benefit.

CONCLUSION

CTCs/CTM had significant prognostic impact and potential role as predictors of ICT benefit in LA-HNSCC.

Abstract LB060: Circulating tumor cells in desmoid tumors

Introduction: Desmoid tumor (DT) is a rare neoplasm with high local recurrence rates. CTNNB1 mutations are found in most sporadic cases and are located in exon 3, usually in codons 41 or 45 (p.T41A, p.S45F and p.S45P). Circulating tumor cells (CTCs) isolated from the peripheral blood of patients with sarcomas and other neoplasms can be early biomarkers of tumor invasion and dissemination. Moreover, CTCs can also re-colonize their tumors of origin through a process of “tumor self-seeding.” Objectives: To identify CTCs in the peripheral blood of patients with DT; to evaluate their expressions of β- catenin and vimentin proteins. Materials and methods: We conducted a prospective study of patients with initially diagnosed and relapsed DT with measurable disease. Blood samples from each patient were processed and filtered by ISET® (Rarecells, France) for the isolation and quantification of CTCs. The expressions of β -catenin and vimentin in CTCs were analyzed by immunocytochemistry (ICC). Results: A total of 18 patients were included, and all had detectable CTCs. We found a concordance of β-catenin expression in CTCs and in primary tumors in 42.85% of cases by using ICC and immunohistochemistry respectively. Conclusions: Our study identified a high prevalence of CTCs in DT patients. Concordance of β-catenin expression between primary tumor and CTCs bring new perspectives to assess the dynamics of CTCs in the blood microenvironment, opening new avenues for studying the biology and behavior of DT. In addition, these results open the possibility of using CTCs to predict DT dynamics at the time of progression and during treatment. Further studies with larger sample sizes are needed to validate our findings.

Citation Format: Alexcia Camila Braun, Fernando Campos, Emne Ali Abdallah, Anna Paula Ruano, Milena Tariki, Fabio Pinto, Celso Abdon de Mello, Vilma Regina Martins, Ludmilla Thome Chinen. Circulating tumor cells in desmoid tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr LB060.

Molecular and Dynamic Evaluation of Proteins Related to Resistance to Neoadjuvant Treatment with Chemoradiotherapy in Circulating Tumor Cells of Patients with Locally Advanced Rectal Cancer

The heterogeneity of response to neoadjuvant chemoradiotherapy (NCRT) is still a challenge in locally advanced rectal cancer (LARC). The evaluation of thymidylate synthase (TYMS) and RAD23 homolog B (RAD23B) expression in circulating tumor cells (CTCs) provides complementary clinical information. CTCs were prospectively evaluated in 166 blood samples (63 patients) with LARC undergoing NCRT. The primary objective was to verify if the absence of RAD23B/TYMS in CTCs would correlate with pathological complete response (pCR). Secondary objectives were to correlate CTC kinetics before (C1)/after NCRT (C2), in addition to the expression of transforming growth factor-β receptor I (TGF-βRI) with survival rates. CTCs were isolated by ISET and evaluated by immunocytochemistry (protein expression). At C1, RAD23B was detected in 54.1% of patients with no pCR and its absence in 91.7% of patients with pCR (p = 0.014); TYMS^- was observed in 90% of patients with pCR and TYMS⁺ in 51.7% without pCR (p = 0.057). Patients with CTC2 > CTC1 had worse disease-free survival (DFS) (p = 0.00025) and overall survival (OS) (p = 0.0036) compared with those with CTC2 ≤ CTC1. TGF-βRI expression in any time correlated with worse DFS (p = 0.059). To conclude, RAD23B/TYMS and CTC kinetics may facilitate the personalized treatment of LARC.

Heterogeneity of HER2 expression in circulating tumor cells of patients with breast cancer brain metastases and impact on brain disease control

2029

Background: The HER2 expression switching in circulating tumor cells (CTC) of breast cancer is dynamic and may have prognostic and predictive clinical implications. This study aims to analyse the association between expression of HER2 in CTC of patients with breast cancer brain metastases (BCBM) and brain disease control. Methods: Exploratory analysis of a prospective assessment (NCT02941536) of CTC before (CTC1) and 4–5 weeks after (CTC2) stereotactic radiotherapy/radiosurgery (SRT). CTC were isolated and quantified by a method of isolation by size of tumors and analyzed by immunocytochemistry to evaluate the expression of HER2. Distant brain failure-free survival (DBFFS), the primary endpoint, and overall survival (OS) were estimated by Kaplan-Meier estimator. Log-rank tests were applied in order to compare the survival curves. For multivariate analysis of prognostic factors that affected DBFFS and OS, the Cox proportional model was adjusted. Results: The median age at SRT was 54 (34-70), the diagnosis-specific graded prognostic assessment (DS-GPA) was 1–2 in 17.5% and 2.5–4 in 82.5% and the primary immunophenotype (PIP) was HER2-enriched in 51%, luminal B (LB) in 31% and triple negative (TN) in 18% of the total of 39 patients. CTC were detected in all 39 patients before SRT and the median CTC1 was 2 CTC/mL. After SRT, CTC were detected in 34 of 35 patients (4 deaths between CTC1 and CTC2) and the median CTC2 was 2.33 CTC/mL. HER2 was expressed in CTC1 and/or CTC2 in 9 patients, of which only 2 patients had PIP HER2-enriched. After a median follow-up of 16.6 months, there were 15 patients with distant brain failure and 16 deaths. The median DBFFS and OS were 15.3 and 19.5 months, respectively. Median DBFFS was 7 months in patients with PIP TN and was not reached in PIP LB and HER2-enriched (p = 0.036); 14 months in patients with DS-GPA 1-2 and 7 months with DS-GPA 2.5-4 (p = 0.017); 10 months in patients without HER2 expressed in CTC and not reached in patients with HER2 expressed in CTC (p = 0.012). Median OS was 4.8 months in patients with PIP TN and was not reached in PIP LB and HER2-enriched (p = 0.0026); 19.54 months in patients with DS-GPA 1-2 and 7.6 months with DS-GPA 2.5-4 (p = 0.00088); 17 months in patients without HER2 expressed in CTC and not reached in patients with HER2 expressed in CTC (p = 0.104). On multivariate analysis, DBFFS was superior in patients with PIP HER2-enriched (HR 0.128, 95% CI 0.025–0.534; p = 0.013) and OS was superior in patients with PIP HER2-enriched (HR 0.073, 95% CI 0.018-0.288; p < 0.0001) and LB (HR 0.224, 95% CI 0.062–0.816; p = 0.023). The status of expression of HER2 in CTC was not included in Cox model for DBFFS due to lack of events in patients with HER2 expressed in CTC. Conclusions: The expression of HER2 in CTC was associated with a longer DBFFS and the switching of HER2 expression between PIP and CTC may have impact on prognosis and treatment selection of BCBM.

Baseline and Kinetic Circulating Tumor Cell Counts Are Prognostic Factors in a Prospective Study of Metastatic Colorectal Cancer

The discovery of predictive biomarkers in metastatic colorectal cancer (mCRC) is essential to improve clinical outcomes. Recent data suggest a potential role of circulating tumor cells (CTCs) as prognostic indicators. We conducted a follow-on analysis from a prospective study of consecutive patients with mCRC. CTC analysis was conducted at two timepoints: baseline (CTC1; before starting chemotherapy), and two months after starting treatment (CTC2). CTC isolation/quantification were completed by ISET^® (Rarecells, France). CTC expressions of drug resistance-associated proteins were evaluated. Progression-free survival (PFS) and overall survival (OS) were estimated by the Kaplan–Meier method. Seventy-five patients were enrolled from May 2012 to May 2014. A CTC1 cut-off of >1.5 CTCs/mL was associated with an inferior median OS compared to lower values. A difference of CTC2−CTC1 > 5.5 CTCs/mL was associated with a reduced median PFS. By multivariate analysis, CTC1 > 1.5 CTCs/mL was an independent prognostic factor for worse OS. Multi-drug resistance protein-1 (MRP-1) expression was associated with poor median OS. CTC baseline counts, kinetics, and MRP-1 expression were predictive of clinical outcomes. Larger studies are warranted to explore the potential clinical benefit of treating mCRC patients with targeted therapeutic regimens guided by CTC findings.

Prospective Assessment of the Association Between Circulating Tumor Cells and Control of Brain Disease After Focal Radiation Therapy of Breast Cancer Brain Metastases

Purpose

Predicting the risk of early distant brain failure (DBF) is in demand for management decisions in patients who are candidates for local treatment of brain metastases. This study aimed to analyze the association between circulating tumor cells (CTCs) and brain disease control after stereotactic radiation therapy/radiosurgery (SRT) for breast cancer brain metastasis (BCBM).

Methods and Materials

We prospectively assessed CTCs before (CTC1) and 4 to 5 weeks after (CTC2) SRT and their relationship with the number of new lesions (NL) suggestive of BCBM before SRT. CTC were quantified and analyzed by immunocytochemistry to evaluate the expression of the proteins COX2, EGFR, ST6GALNAC5, NOTCH1, and HER2. Distant brain failure-free survival (DBFFS), the primary endpoint, diffuse DBFFS (D-DBFFS), and overall survival were estimated. Analysis for DBF within 6 months, with death as competing risk, was performed.

Results

Patients were included between 2016 and 2018. CTCs were detected in all 39 patients before and in 34 of 35 patients after SRT. After median follow-up of 16.6 months, median DBFFS, D-DBFFS, and overall survival were 15.3, 14.1, and 19.5 months, respectively. DBF at 6 months was 40% with CTC1 ≤0.5 and 8.82% with CTC1 >0.5 CTC/mL (P = .007), and D-DBF at 6 months was 40% with CTC1 ≤0.5 and 0 with CTC1 >0.5 CTC/mL (P = .005) and 25% with NL/CTC1 >6.8 and 2.65% with NL/CTC1 ≤6.8 (P = .063). On multivariate analysis, DBFFS was inferior with CTC1 ≤0.5 (hazard ratio, 8.27; 95% confidence interval, 2.12-32.3; P = .002), and D-DBFFS was inferior with CTC1 ≤0.5 (hazard ratio, 10.22; 95% confidence interval, 1.99-52.41; P = .005). Protein expression was not associated with outcomes.

Conclusions

These data suggest that CTC1 and NL/CTC1 may have a role as a biomarker of early diffuse DBF and as a subsequent guide between focal or whole-brain radiation therapy in patients with BCBM.

Prospective study with circulating tumor cells as potential prognosis biomarker in metastatic colorectal cancer

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Background: Colorectal cancer (CRC) is one of the most common cancer worldwide. Around 30% present metastatic disease at diagnosis and 50%–60% of patients develop metastasis. New prognostic markers are needed and circulating tumor cells (CTCs) are a promising tool. Methods: Prospective study conducted by blood collection from 75 patients (pts) with metastatic CRC (mCRC), twice, with 2 months interval, together with image exams for therapeutic response evaluation. CTCs were detected by ISET and identified by immunocytochemistry. Results: The mean age was 57.3 years old (24-81). RAS mutations in primary tumor was found in 38% (19/50) of patients (pts) and left colon topography in 41.3% (31/75). Comparing the baseline CTC level (CTC1) with the level at first follow-up (CTC 2), pts with CTC2 – CTC1 > 5.5 per ml demonstrated poor progression-free survival (PFS) (3.2 months) when compared to CTC 2 – CTC1 ≤ 5.5 (9.1 months) (p= 0.005). The median overall survival (OS) was 24.5 months for pts with CTC 1 > 1.5 per ml and 34.2 months for those with CTC1 ≤ 1.5 per (HR=1.89, 95% CI, 1.01 to 3.52; p= 0.041). Patients with RAS mutation (P= 0.001), primary tumor in the right colon (p= 0.014) and expression of Multidrug Resistance Protein 1 in CTCs (p= 0.044) had worse OS. By multivariable analyses, CTC 1 > 1.5/mL (p= 0.025) was an independent prognostic factor. Conclusions: This prospective study confirmed that counts of CTCs at baseline (CTC1) is an important prognostic marker for monitoring mCRC and correlates with other established prognostic factors. Clinical trial information: NCT02979470.

Prognostic impact of baseline circulating tumor cells (CTCs) detected by the isolation by size of epithelial tumor cells (ISET) in locally advanced head and neck squamous cell carcinoma (LAHNSCC): Results of a prospective study

6061

Background: The prognostic impact of CTCs in LAHNSCC is yet to be determined, with conflicting results in previous trials, the majority utilizing cytokeratin dependent techniques for identification and counting of CTCs. The primary objective of this study is to determine the detection rates using the ISET method, and the prognostic role of CTCs in LAHNSCC patients (pts) treated with a curative intent. Methods: In this prospective study, peripheral blood samples of pts with non-metastatic LAHNSCC, stages III/IV, were analyzed for CTCs using the ISET method, in two scenarios: curative surgical resection and adjuvant radiotherapy (CTCs before RT) and candidates for a non-surgical strategy (unresectable or organ preservation) either with upfront RT concurrent with chemotherapy (CT) or cetuximab (CTCs before RT), or preceded by induction CT (CTCs before ICT). Results: Eighty-three pts were included, the majority males (83%), with oropharynx primary (50%) and submitted to ICT (40%). The detection rate of baseline CTCs was 94% (78/83), and CTCs counts were significantly correlated with survival. For each increase of 1 CTC at baseline there was a relative increase of 18% in the risk of death (HR = 1.18; 95%CI: 1.06-1.31; p < 0.001), 16% in the risk of progression (HR = 1.16; 95%CI: 1.04-1.28; p = 0.004) and a reduction of 26% in the odds of complete response to treatment (non-surgical group only - OR = 0.74; 95%CI: 0.58-0.95; p = 0.022). Using the maximum of the standardized log-rank statistic proposed by Lausen and Schumacher we establish cut off points for overall survival (OS) and progression-free survival (PFS). Pts with CTCs < 6.5/ml had an estimated 2y OS of 85.6% versus 22.9% for CTCs ≥ 6.5/ml (HR = 0.18; 95%CI: 0.06-0.49; P < 0.0001) and pts with CTCs ≤ 3.8/ml had an estimated 2y PFS of 71.8% versus 37% for CTCs > 3.8/ml (HR = 0.32; 95%CI:0.15-0.67; p = 0.001). Conclusions: The detection rate of baseline CTCs using the ISET method was very high in LAHNSCC and the counts of CTCs were strongly correlated with survival and response to treatment.

EVALUATING MMP-2 AND TGFß-RI EXPRESSION IN CIRCULATING TUMOR CELLS OF PANCREATIC CANCER PATIENTS AND THEIR CORRELATION WITH CLINICAL EVOLUTION

BACKGROUND

Metastasis is common in the diagnosis of pancreatic cancer, and the presence of epithelial-mesenchymal transition markers in circulating tumor cells may suggest worse prognosis.

AIM

To correlate the number of circulating tumor cells (CTCs) in the peripheral blood of patients with a locally advanced or metastatic pancreatic tumor and the protein expression involved in epithelial-mesenchymal transition (EMT) in CTCs with clinical characteristics, progression-free survival (PFS) and overall survival (OS).

METHOD

This was a prospective study conducted using peripheral blood samples collected at three different times. CTCs were quantified by the ISET test and analyzed by immunocytochemistry. Proteins involved in EMT (vimentin, TGFß-RI and MMP2) were analyzed in all CTCs.

RESULTS

Twenty-one patients were included. Median CTCs detected were 22, 20 and 8 CTCs/8 ml blood at baseline, first and second follow-up, respectively. No statistically significant correlation was found in correlating the number of CTCs and the evaluated clinical characteristics, PFS, or OS. There was no difference in PFS and OS among the EMT markers in the groups with and without markers.

CONCLUSION

CTC analysis was not relevant in this sample for comparing clinical findings, PFS and OS in patients with pancreatic cancer. However, marker analysis in CTCs could be useful for the MMP-2 and/or TGFß-RI expression, as observed by the separate PFS curve.

Abstract 5189: Evaluation of thymidylate synthase mRNA expression in circulating tumor cells from non-metastatic colon and rectal patients

Background: colorectal cancer is the third leading cause of cancer death in the United States. With different behaviors, rectal cancer represents worse prognosis, even in the locally advanced setting, with therapy following three steps, consisting of neoadjuvant chemoradiation, surgery and adjuvant chemotherapy. For non-metastatic colon cancer, the main treatment is surgery and then, patients can or not undergo adjuvant chemotherapy. Studies have shown that circulating tumor cells (CTCs) may be involved in metastatization process. Thymidylate synthase (TYMS) acts in the 5-Fluorouracil metabolism, and when overexpressed, can confer resistance to treatment, which is commonly used for neoadjuvant treatment (rectal cancer) and in combination with oxaliplatin for adjuvant treatment (colon cancer). Excision repair cross complementation Group 1 (ERCC1) is a protein involved in damage DNA repair process that is described to confer resistance to platinum-based chemotherapy. Objective: evaluate the TYMS messenger RNA (mRNA) expression in CTCs isolated from patients with locally advanced colon and rectal cancers; and its predictable value in treatment resistance. For patients with colon cancer, we also evaluated the ERCC1 protein expression in order to verify the adjuvant therapy resistance related to oxaliplatin. Methods: We collected 10 mL of blood before the beginning of treatment and processed it on ISET® (Rarecells) device. RNAscope® Technology is a novel chromogenic in situ hybridization (CISH) assay for detection of target RNA within intact cells. The expression of TYMS target gene was performed using the kit from ACDbio, as described on the protocol, but standardized to cytology. Results: there were included 12 patients of each type of tumor. We analyzed samples from 12 rectal cancer patients, and found 10 with overexpression of TYMS mRNA in CTCs. Curiously, of the two patients who had TYMSneg mRNA expression; one had complete pathological response and the other substantial down-staging. In the positive cases, 50% presented response (partial or complete) and 50% present no response and systemic progression. This result will better understood when we perform the evaluation of the protein TYMS. Among the samples from colon cancer patients, we found 8 out 12 as CTCs TYMSpos mRNA expression. Unfortunately, our recent data does not allow us to do analysis of recurrence. However, one of the positive cases had recurrence. Among the 4 TYMSneg, one had recurrence. This can be explained by the positive immunocytochemical expression of the ERCC1 protein, which confers resistance to oxaliplatin. Our next steps are to expand the CISH experiments in a larger group of patients as well as to evaluate the TYMS protein expression in the same cases. Conclusion: our preliminary results point molecular analysis of CTCs as predictor marker of colon/rectal cancer treatments.

Citation Format: Bianca Troncarelli Flores, Emne Ali Abdallah, Virgílio Souza e Silva, Celso Abdon Mello, Samuel Aguiar, Renata Mayumi Takahashi, Vanessa Silva Alves, Bruna Elisa Kupper, Ludmilla T. Chinen. Evaluation of thymidylate synthase mRNA expression in circulating tumor cells from non-metastatic colon and rectal patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5189.

Abstract 1569: Circulating tumor cells and circulating tumor microemboli in the context of gastric adenocarcinoma

Background: Whereas the pathological aspects of Gastric Adenocarcinomas (GAC) are well defined, there is still an important lack of biomarkers predictive of its occurrence, aggressiveness and response to neoadjuvant treatment. Nowadays, it is known that isolated or clustered Circulating Tumor Cells (respectively CTCs or CTMs, for Microemboli) can be found in the blood of patients many months before tumor detection. In this sense, the identification of CTCs/CTMs in GAC patients has a potential value as biomarkers for tumor growth and invasiveness.

Objective: to study the predictive value of CTCs and CTMs from GAC patients, evaluating their presence and correlation with HER2-status and clinical-pathological characteristics.

Methods: Blood was prospectively collected from 72 GAC patients (62.5% men) recruited at the Department of Abdominal Surgery of the A.C.Camargo Cancer Center, São Paulo, Brazil, from March 2016 to March 2017, after the signature of informed consent forms previously approved by the institutional review board. Blood was first collected before the first neoadjuvant cycle (at diagnosis) and also before adjuvant treatment (diagnosis of metastasis). The samples were processed and filtered in ISET (Rarecells, France) allowing the isolation and quantification of CTCs and CTMs, and immunocytochemistry (ICC) with anti-HER2.

Results: The most common tumor status were T1b (15/20.8%) and N1 (14/19.4%) and diffuse tumors (Lauren's) was the most common subtype (37/51.4%); 55 patients had non-metastatic disease (76.4%) at moment of inclusion. CTCs were found in 61/72 patients (84.7%) with a median of 2.5 CTCs/mL (0-39.6 CTCs/mL). We found more CTC/mL in non-metastatic disease (2.8 CTCs/mL versus 0.9 CTCs/mL, p&lt;0.001). CTMs were found in 28 patients (38.9%) and we also found more CTCs/mL CTM-positive cases (p&lt;0.001). Among non-metastatic disease, 23/55 patients had CTM (41.8%) and in the metastatic scenario, 5/16 patients had CTM (31.3%). Besides finding no differences in the amount of CTCs between histological subtypes (intestinal versus diffuse), we observed more CTMs on diffuse GAC subtype compared to intestinal (69.6% x 30.4%). HER-2 status was evaluated in CTCs and primary tumor derived from 40 patients, with a level of concordance of 67.5%.

Conclusions: CTCs were more prevalent in patients with initial disease, reinforcing their possible role in the growth of the primary tumor maybe in a self-seeding mechanism. Also, the good HER2-correlation found between primary tumors and CTCs suggest the use of the later as surrogates of the primary tumor for determining targeted therapies with anti-HER2 antibodies.

Citation Format: Emne Ali Abdallah, Alexcia Camila Braun, Bianca Troncarelli Flores, Lais Lie Senda, Maria Dirlei Ferreira de Souza Begnami, Felipe José Coimbra, Emmanuel Dias-Neto, Diana Nunes, Wilson Luiz Costa Junior, Ludmilla T. Chinen. Circulating tumor cells and circulating tumor microemboli in the context of gastric adenocarcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1569.

EGFR expression in circulating tumor cells from high-grade metastatic soft tissue sarcomas

INTRODUCTION

Soft tissue Sarcomas (STS) are rare malignances, with high mortality rates. Half of patients develop metastasis. The presence of isolated Circulating Tumor Cells (CTCs) and Circulating Tumor Microemboli (CTM) in the blood may be early markers of tumor invasion. Epidermal Growth Factor (EGF) family receptors can also influence this process.

OBJECTIVES

to quantify CTCs and identify CTM as well as the EGF Receptor (EGFR) protein expression in these cells and correlate with clinical outcome in metastatic STS.

MATERIALS AND METHODS

Approximately 8mL of blood was prospectively collected from patients with different types of high-grade STS, before the beginning of chemotherapy. The samples were processed and filtered by ISET (Rarecells, France) for the isolation and quantification of CTCs and CTMs. EGFR expression was analyzed by immunocytochemistry (ICC) on CTCs/ CTMs.

RESULTS

We analyzed 18 patients with median age of 49 years (18-77 y). The positivity for EGFR protein expression in CTCs was observed in 93.75% of the patients. This result shows that targeting EGFR positive CTCs from STS origen can be translated in clinical benefit for some patients. In addition, if target therapy is chosen, the EGFR expression in CTCs can be used in follow-up to measure treatment effectiveness.

CONCLUSIONS

This is the first study to demonstrate the expression of EGFR protein in CTCs from sarcoma patients. It may open an area for future investigations. The next step is to characterize CTCs in a larger cohort of patients to better understand the role of EGFR in sustaining tumor metastasis in sarcomas.

Circulating Tumor Cells as Cancer Biomarkers in the Clinic

It is believed that the development of metastatic cancer requires the presence of circulating tumor cells (CTCs) , which are found in a patient's circulation as rare abnormal cells comingled with billions of the normal red and white blood cells. The systems developed for detection of CTCs have brought progress to cancer treatment. The molecular characterization of CTCs can aid in the development of new drugs, and their presence during treatment can help clinicians determine the prognosis of the patient. Studies have been carried out in patients early in the disease course, with only primary tumors, and the role of CTCs in prognosis seems to be as important as it is in patients with metastatic disease. The published studies on CTCs have focused on their prognostic significance, their utility in real-time monitoring of therapies, the identification of therapeutic and resistance targets, and understanding the process of metastasis . The analysis of CTCs during the early stages, as a "liquid biopsy," helps to monitor patients at different points in the disease course, including minimal residual disease, providing valuable information about the very early assessment of treatment effectiveness. Finally, CTCs can be used to screen patients with family histories of cancer or with diseases that can lead to the development of cancer. With standard protocols, this easily obtained and practical tool can be used to prevent the growth and spread of cancer. In this chapter, we review some important aspects of CTCs , surveying the disease aspects where these cells have been investigated.

MRP1 expression in CTCs confers resistance to irinotecan-based chemotherapy in metastatic colorectal cancer

Circulating tumor cells are important markers of tumor progression and can reflect tumor behavior in metastatic colorectal cancer (mCRC). Identification of proteins that confer resistance to treatment is an important step to predict response and better selection of treatment for patients. Multidrug resistance-associated protein 1 (MRP1) and Multidrug resistance-associated protein 4 (MRP4) play a role in irinotecan-resistance, and Excision Repair Cross-Complementation group 1 (ERCC1) expression can confer resistance to platinum compounds. Here, we included 34 patients with mCRC and most of them received FOLFIRI or FOLFOX chemotherapy (91.1%). CTCs were isolated by ISET(®) Technology and identified in 30 patients (88.2%), with a median of 2.0 CTCs/mL (0-31.0). We analyzed the immunocytochemical expression of MRP1, MRP4 and ERCC1 only in patients who had previously detectable CTCs, accordingly to treatment received (n = 19, 15 and 13 patients, respectively). Among patients treated with irinotecan-based chemotherapy, 4 out of 19 cases with MRP1 positive CTCs showed a worse progression free survival (PFS) in comparison to those with MRP1 negative CTCs (2.1 months vs. 9.1 months; p = 0.003). None of the other proteins studied in CTCs had significant association with PFS. We analyzed also histological sections of primary tumors and metastases by immunohistochemistry, and found no association with clinicopathological characteristics or with PFS. Our results show MRP1 as a potential biomarker of resistance to treatment with irinotecan when found in CTCs from mCRC patients. This is a small proof-of-principle study and these early findings need to be validated in a larger cohort of patients.

Thymidylate synthase expression in circulating tumor cells: a new tool to predict 5-fluorouracil resistance in metastatic colorectal cancer patients

Thymidylate synthase (TYMS) is an important enzyme for 5‐fluorouracil (5‐FU) metabolism in metastatic colorectal cancer (mCRC) patients. The search for this enzyme in circulating tumor cells (CTCs) can be a powerful tool to follow‐up cancer patients. mCRC patients were enrolled before the beginning of 5‐FU‐based chemotherapy. The blood was filtered on Isolation by Size of Epithelial Tumor Cells (ISET), and the analysis of TYMS expression in CTCs was made by immunocytochemistry. Additionally, we verified TYMS staining in primary tumors and metastases from the same patients. There were included 54 mCRC patients and 47 of them received 5‐FU‐based chemotherapy. The median CTCs number was 2 per mL. We were not able to analyze immunocytochemistry in 13 samples (9 patients with absence of CTCs and 4 samples due to technical reasons). Therefore, TYMS expression on CTCs was analyzed in 34 samples and was found positive in 9 (26.5%). Six of these patients had tumor progression after treatment with 5‐FU. We found an association between CTC TYMS staining and disease progression (DP), although without statistical significance (P = 0.07). TYMS staining in primary tumors and metastases tissues did not have any correlation with disease progression (P = 0.67 and P = 0.42 respectively). Patients who had CTC count above the median (2 CTCs/mL) showed more TYMS expression (P = 0.02) correlating with worse prognosis. Our results searching for TYMS staining in CTCs, primary tumors and metastases suggest that the analysis of TYMS can be useful tool as a 5‐FU resistance predictor biomarker if analyzed in CTCs from mCRC patients.

What's new?

Currently, the common treatment strategy for metastatic colorectal cancer patients is 5‐Fluorouracil‐based chemotherapy, which shows high efficacy in a subset of patients. Even those patients, however, can experience disease progression due to 5‐FU resistance. There are indications that the DNA replication and repair enzyme thymidylate synthase (TYMS) may be involved. Here, the authors set to measure circulating tumor cells levels and search for TYMS staining to correlate these findings with clinical outcome. The results suggest that circulating tumor cells represent a powerful tool to follow up 5‐FU resistance in metastatic colorectal cancer patients in real time, by TYMS expression analysis.

Abstract LB-194: The presence of TYMS immunostaining in circulating tumor cells is a predictive biomarker in colorectal cancer

Background: colorectal cancer (CRC) was the third most commonly diagnosed cancer in both men and women in the last three years in the United States (Siegel et al., 2011, 2012, 2013). The first strategy for treatment is complete resection of the lesion. However, some patients experience recurrence, believed to be due to residual resistant micrometastases. Circulating tumor cells (CTCs) have been considered an important prognostic biomarker and crucial for tumor dissemination. Traditional diagnostic methods are unable to detect CTCs present in these sites and released into the circulation. Objective: to count CTCs levels and search for Thymidylate synthase (TYMS), a drug resistance gene, in these cells from patients with metastatic or advanced colorectal cancer. Methods: prospective study made by blood collection of patients with metastatic or advanced CRC. Blood was collected before the beginning of chemotherapy and after 60 days, in accordance with image exams. The sample was filtered on ISET (Isolation by Size of Epithelial Tumor Cells) according to manufacture procedure. CTCs fixed on spots from ISET membranes were stained by immunocytochemistry with anti-TYMS antibody and counterstained with hematoxylin-eosyn. Leucocytes were identified by anti-CD45 antibody. CTCs were analised by light microscope and quantified by 1 mL of blood. Results: there were included 42 patients. 78.5% were treated with FOLFOX or FOLFORI. The median age was 58 years-old (30-81). The majority of patients was men (59.5%) and included at stage IV of disease (88%). The median CTCs numbers detected in all patients were 2.18 CTCs/ml (0- 31.25) at baseline. Immunostaining in CTCs with TYMS was performed in 41 samples. Nine (21.9%) were found positive. Six of these patients had tumor progression in a follow-up of 12 months after treatment with 5-FU. Among patients with CTC TYMS positive and disease progression, 4 had also tumor tissue positive. Conclusion: It is been related in literature that high tissue expression of TYMS shows worse response to 5-FU-based chemotherapy (Lurje et al., 2009). Our results with CTCs expressing TYMS strongly contribute with these findings and suggest that maybe these cells can be used as a predictor biomarker of chemotherapy response. Furthermore, CTCs levels may offer a novel approach to follow up patients in an individualized manner.

Citation Format: Ludmilla T. Chinen, Emne Ali Abdallah, Virgilio S. Silva, Marcilei E. Buim, Marcelo Calil Neto, Jose Luiz Gasparini Junior, Bruna Maria Malagoli Rocha, Juliana R. Romero, Natalia Breve Mingues, Fernando Augusto Soares, Mitzi Brentani, Marcello Ferretti Fanelli. The presence of TYMS immunostaining in circulating tumor cells is a predictive biomarker in colorectal cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr LB-194. doi:10.1158/1538-7445.AM2014-LB-194

Isolation, detection, and immunomorphological characterization of circulating tumor cells (CTCs) from patients with different types of sarcoma using isolation by size of tumor cells: a window on sarcoma-cell invasion

Background

Sarcomas are rare and heterogeneous neoplasms with poor prognosis that are thought to spread to distant organs mainly by hematogenous dissemination. However, circulating tumor cells (CTCs) have never been visualized in sarcomas.

Objectives

To investigate the feasibility of using isolation by size of tumor cells (ISET) for isolation, identification, and characterization of CTCs derived from patients with high-grade and metastatic sarcomas.

Patients and methods

We studied eleven patients with metastatic/recurrent or locally advanced soft-tissue sarcomas (STSs), six of whom had synovial sarcomas. Blood samples (8 mL) were collected from patients with advanced STS and treated by ISET, a marker- independent approach that isolates intact CTCs from blood, based on their larger size compared with leukocytes. CTCs were identified by cytomorphology and characterized by dual-color immunocytochemistry using antivimentin or anti-Pan CK, and anti-CD45.

Results

All patients with STS included in this study showed CTCs, with numbers ranging from two to 48 per 8 mL of blood.

Conclusion

This study shows the feasibility of isolating, identifying, and characterizing CTCs from patients with different types of sarcomas and the presence of circulating sarcoma cells in all the tested patients. Our results set the basis for further studies aimed at exploring the presence, number, and immunomolecular characteristics of CTCs in different types of sarcoma, and bring more light to the mechanisms of tumor invasion for these tumors.

Cytokeratin-based CTC counting unrelated to clinical follow up

BACKGROUND

Circulating tumor cells (CTCs) have been reported to be a relevant prognostic biomarker in metastatic patients. However, their clinical use and impact is still under debate. We have thus comparatively and kinetically assessed two CTC detection methods according to the patient's clinical follow up.

METHODS

CTC counting and characterization were repeatedly performed during follow up in a patient with metastatic undifferentiated non-small cell lung cancer by using cytokeratin (CK)-dependent immunomagnetic separation (Miltenyi) and CK-independent, size-based isolation [isolation by size of tumor cells (ISET)] (Rarecells).

RESULTS

Comparison between the two methods showed a parallel increase of CTC detected by ISET and worsening of the clinical status, while CK-dependent CTC numbers were decreasing, misleadingly suggesting a response to treatment. ISET results were in agreement with the clinical follow up showing Circulating tumor microemboli (CTM) and CTC expressing a mesenchymal marker with absence of epithelial markers.

CONCLUSIONS

This case report study shows the interest of a comparative and kinetic analysis of different methods for CTCs detection combined with their evaluation according to the clinical follow up. Our results should open up an area for future research and validation in larger clinical cohorts.

Differential effects of paraoxon on the M3 muscarinic receptor and its effector system in rat submaxillary gland cells

The effects of the organophosphorus anticholinesterase paraoxon on the binding of radioactive ligands to the M3 subtype of the muscarinic receptor and receptor-coupled synthesis of second messengers in intact rat submaxillary gland (SMG) cells were investigated. The binding of [3H]quinuclidinyl benzilate ([3H]QNB) was most sensitive to atropine and the M3-specific antagonist 4-DAMP followed by pirenzepine and least sensitive to the cardioselective M2 antagonist AFDX116. This, and the binding characteristics of [3H]4-DAMP, confirmed that the muscarinic receptors in this preparation are of the M3 subtype. Activation of these muscarinic receptors by carbamylcholine (CBC) produced both stimulation of phosphoinositide (PI) hydrolysis and inhibition of cAMP synthesis, suggesting that this receptor subtype couples to both effector systems. Paraoxon (100 microM) reduced Bmax of [3H]4-DAMP binding from 27 +/- 4 to 13 +/- 3 fmol/mg protein with nonsignificant change in affinity, suggesting noncompetitive inhibition of binding by paraoxon. Like the agonist CBC, paraoxon inhibited the forskolin-induced cAMP formation in SMG cells with an EC50 of 200 nM, but paraoxon was greater than 500 fold more potent than CBC. However, while the inhibition by CBC was counteracted by 2 microM atropine, that by paraoxon was unaffected by up to 100 microM atropine. It suggested that this effect of paraoxon was not via binding to the muscarinic receptor. Paraoxon did not affect beta-adrenoreceptor function in the preparation, since it did not affect the 10 microM isoproterenol-induced cAMP synthesis, which was inhibited totally by 10 microM propranolol and partially by CBC. Paraoxon had a small but significant effect on CBC-stimulated PI metabolism in the SMG cells.(ABSTRACT TRUNCATED AT 250 WORDS)

The presence of an M4 subtype muscarinic receptor in the bovine adrenal medulla revealed by mRNA and receptor binding analyses

The muscarinic receptor subtype present in the bovine adrenal medulla was characterized. Hybridization of RNA to highly specific m1-m5 muscarinic receptor cDNA probes detected the presence of only m4 subtype mRNA in this tissue. Muscarinic receptor binding studies using the non-selective ligand [3H]N-methyl-scopolamine showed a single class of binding sites with a maximum density of 19.8 fmol/mg protein and a dissociation constant (KD) of 220 pM in the adrenal medulla, while the M1 selective ligand [3H]telenzepine did not bind detectably. Competition of specific antagonists with [3H]N-methyl-scopolamine for binding to the membranes produced a rank order of potencies with a profile that fitted either the cloned m3 or m4 receptor. In further comparative studies, the adrenal gland of the rat showed the presence of m4 subtype mRNA in addition to the m3 subtype.

DFP-induced regulation of cardiac muscarinic receptor mRNA in vivo measured by DNA-excess solution hybridization

Relationship between in vivo down-regulation of cardiac muscarinic receptors and changes in their encoding mRNA was investigated. Rats were treated either once or for ten days with an irreversible inhibitor of acetylcholinesterase, followed by measurements of cardiac acetylcholinesterase, the density and affinity of muscarinic receptors, and the concentration of mRNA coding for these receptors. mRNA was quantitated using the sensitive method of DNA-excess solution hybridization. Our data indicate that while short-term treatment resulted in a marked decrease in the density of cardiac muscarinic receptors by 34%, there was no accompanying significant change in the concentration of their mRNA. In contrast, long-term inhibition of acetylcholinesterase significantly decreased the concentration of both receptors and mRNA by 40% and 29%, respectively. These results are indicative of multiple mechanisms of down-regulation of cardiac muscarinic receptors, some of which might involve alterations at the transcriptional level.

Lack of desensitization of muscarinic receptor-mediated second messenger signals in rat brain upon acute and chronic inhibition of acetylcholinesterase

We studied the effects of acute and chronic in vivo inhibition of acetylcholinesterase on both the density and function of brain muscarinic cholinergic receptors. Adult male rats were treated either once or multiple times over a period of 10 days with the irreversible acetylcholinesterase inhibitor diisopropylfluorophosphate (DFP). The concentration and affinity of muscarinic receptors in various brain regions were determined using radioligand binding techniques. Acute DFP treatment resulted in a significant reduction in receptor number only in the brain stem, while chronic treatment caused receptor down-regulation in the brain stem, cerebral cortex, and striatum. There was no change in ligand affinity in any of the brain regions. In sharp contrast, muscarinic receptor function was fully preserved, in terms of coupling of the receptors to increased phosphoinositide hydrolysis in the cerebral cortex, hippocampus, and striatum, or inhibition of cyclic AMP formation in the cerebral cortex or striatum. Therefore, there is a marked lack or correlation between DFP-induced muscarinic receptor down-regulation and receptor desensitization.

Aging does not alter muscarinic receptor-mediated inhibition of cyclic AMP formation in the striatum and hippocampus

The effects of aging on the inhibition of forskolin-stimulated cyclic AMP formation by muscarinic receptors were investigated. There were no detectable changes in the magnitude of maximal inhibition by carbamylcholine or the potency of the agonist in inducing this response in either the striatum or hippocampus obtained from young or old Fisher 344 rats.

Relationship between the partial inhibition of muscarinic receptor-mediated phosphoinositide hydrolysis by phorbol esters and tetrodotoxin in rat cerebral cortex

Our results demonstrate that phorbol esters and tetrodotoxin (TTX) partially inhibit muscarinic receptor-mediated increase in phosphoinositide (PI) hydrolysis in rat cerebral cortex cell aggregates; this inhibition was observed using several muscarinic agonists. While these effects were not accompanied by major changes in the total muscarinic receptor population, phorbol esters, but not TTX, reduced the relative concentration of the high affinity binding sites of the M1-selective ligands pirenzepine and telenzepine. In contrast, the binding of a muscarinic agonist to multiple receptor conformations was not influenced by either phorbol esters or TTX. Our data also show that the partial inhibition of the PI response by these agents is not due to a selective effect on the response mediated by a certain muscarinic receptor subtype or a receptor population which is more sensitive to agonist-induced desensitization. Evidence is provided that the effects of both phorbol esters and TTX might be mediated largely, although not entirely, by a common mechanism.

Aging does not alter brain muscarinic receptor-mediated phosphoinositide hydrolysis and its inhibition by phorbol esters, tetrodotoxin and receptor desensitization

The effects of aging on muscarinic receptor-mediated phosphoinositide (PI) hydrolysis in the brain were investigated in Fischer-344 rats. Oxotremorine-M stimulated this response to the same magnitude in young and old rats in the cerebral cortex, striatum, hippocampus, thalamus, hypothalamus and cerebellum, although maximal stimulation varied among brain regions within each age group. The PI response was also equally potentiated by elevated K+ or suppressed by tetrodotoxin in both age groups. In addition, a phorbol ester attenuated muscarinic receptor-mediated PI hydrolysis in the cerebral cortex to the same extent in young and aged rats. Moreover, preincubation with oxotremorine-M resulted in a similar down-regulation of cell-surface receptors and desensitization of receptor function regardless of age. Therefore, under our experimental conditions, PI hydrolysis in response to activation of brain muscarinic receptors does not appear to be sensitive to aging-related alterations.