Abstract P4-01-01: Molecular residual disease detection with circulating tumor DNA analysis predicts relapse in patients with early stage breast cancer

Background. Detection of circulating tumor DNA (ctDNA) after treatment of early stage breast cancer may identify molecular residual disease. In a prior proof-of-principle study we demonstrated that detection of ctDNA predicted relapse with high accuracy (Garcia-Murillas et al Science Trans Med 2015). We conducted an independent, prospective, multi-centre validation study.

Methods. In this validation study, a cohort of 170 early stage breast cancer patients were recruited from five hospitals into two prospective sample collection studies. Patients were scheduled to receive standard chemotherapy, surgery +/- radiotherapy, adjuvant endocrine therapy and HER2 antibodies as appropriate. Plasma samples were collected for ctDNA analysis at baseline, post-surgery, three monthly for the first year of follow-up, and six monthly thereafter and shipped to a central lab for processing. Using previously established criteria, tumor was sequenced to identify somatic mutations that were tracked by digital PCR in DNA extracted from 4mls of plasma at all available time points. Buffy coat DNA was analysed at all time-points to control for clonal haematopoesis of indeterminate potential (CHIP) detection. The primary endpoint was to compare invasive disease free survival between patients with and without detection of ctDNA after treatment. A combined analysis of this validation study, and the prior proof-of-principle study, was also conducted to analyse secondary endpoints.

Results. After tumor sequencing, 101 patients from the validation study had at least one mutation to track. At median 35.5 months follow-up, ctDNA was detected in plasma of 15.8% (16/101) patients. Detection of ctDNA strongly predicted relapse, hazard ratio 24.5 (95% CI 6.5 to 93.2, P<0.001 time-dependent Cox model), and was predictive of relapse in all tumor subtypes.

In the combined analysis (N=144), lead-time between ctDNA detection and relapse was 10.7 months (95% CI 7.7-17.0). Six patients had a clinical relapse that was not detected by ctDNA prior to relapse. These patients had a distinct pattern of oligo-metastatic relapse, 3 patients with brain-only metastases (P=0.0068), 1 ovarian oligo-metastasis and 2 local disease recurrence. The level of ctDNA in baseline plasma, prior to treatment, was associated with tumor subtype, highest in triple negative breast cancer (P=0.0036).

Conclusion. Detection of ctDNA after treatment is associated with a high risk of future relapse in early-stage breast cancer. Prospective studies are required to assess the potential of molecular residual disease detection to guide adjuvant therapy.

Citation Format: Turner N, Garcia-Murillas I, Chopra N, Comino-Mendez I, Beaney M, Tovey H, Cutts R, Swift C, Kriplani D, Afentakis M, Hrebien S, Walsh G, Johnston S, Ring A, Russell S, Evans A, Skene A, Wheatley D, Dowsett M, Smith I. Molecular residual disease detection with circulating tumor DNA analysis predicts relapse in patients with early stage breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-01-01.

Abstract P4-15-01: Acquired ESR1 mutation and persistent expression of estrogen regulated genes in ER+ breast cancers on long-term neoadjuvant treatment with aromatase inhibitors

Background: Aromatase inhibitors (AI), which block the conversion of androgen to estrogen, are the mainstay therapy for estrogen receptor–positive (ER+) breast cancer (BC). However, many patients relapse.

Purpose: To identify molecular alterations associated with long-term neoadjuvant AI therapy of ER+ BC.

Methods: We retrospectively identified 137 patients diagnosed with ER+ BC and treated with neoadjuvant AI for at least 1 month at the Royal Marsden Hospital (2003–2016). Paired pre- (diagnosis) and post-AI (surgery) biopsies with >40% invasive cell areas were available from 87 ER+ BC patients. In all samples, we evaluated ER, PR and Ki67 immunostaining, ESR1 hot-spot mutations by droplet digital PCR and expression of 801 genes associated with BC and response to endocrine therapy by NanoString.

Results: Mean time on neoadjuvant treatment was 26 weeks (range 5.6–92.3). Cell proliferation remained suppressed in most tumours indicating little evidence for acquired resistance: 56/87 (64%) showed residual Ki67 (Ki67r) <2.7% (complete cell cycle arrest) and 14/87 (11.5%) had Ki67r>10%. This was paralleled by reduced expression of proliferation genes, ER (immunostaining and gene expression) and estrogen-regulated genes (ERG) at surgery compared with the diagnostic samples (all p<0.001). There was a weak positive correlation between AI duration and Ki67r and less reduction in proliferation genes, ESR1 and ERGs expression (p<0.05; r=0.26-0.34). Pathway analysis revealed inhibition of cell cycle (e.g. reduced expression of several cyclins), E2F targets and estrogen response (e.g. reduced expression of ER downstream targets such as FOXM1). CDK genes showed a variable response: CDK1 and CDK2 decreasing, CDK4 increasing and no change in CDK6. Most notably, 6 surgical samples showed ESR1 mutations: one of these cases had the mutation at diagnosis. All 5 acquired mutations were detected in patients treated for >6 months, giving a prevalence in this cohort of 5/34 (15%). Tumours with ESR1 mutations showed less suppression of ERGs (p=0.002) and proliferation (p=0.039) and increased ESR1 (p=0.016) expression at surgery compared with tumours without mutation. Pathway analysis confirmed lack of inhibition of estrogen response (FDR>5%) and less inhibition of cell cycle [enrichment score: -0.49 vs -0.78) and E2F targets (-0.47 vs -0.8) in tumours with mutation. Tumours without ESR1 mutation but with Ki67r>10% also showed reduced ERGs response (p=0.006) compared to tumours with Ki67r<2.7%. Additionally, these tumours showed relative activation of cell cycle, estrogen response, E2F targets pathways and mTORC1 signalling (FDR<1%).

Conclusion: Overall most tumours showed no evidence for the emergence of resistant disease after neoadjuvant AI therapy even after many months of treatment. However, we detected an enrichment of ESR1 mutations (15% of cases) after long-term treatment as a putative driver of ERG expression and proliferation and thus reduced AI response. Therefore, mutant ER appears to be associated with ligand-independent ERG activity supporting the clinical validity of dual blockade with a selective ER down-regulator combined with a CDK4/6 inhibitor targeting the RB/E2F axis in this scenario.

Citation Format: Leal MF, Haynes BP, Schuster E, Yeo B, Afentakis M, Dodson A, Buus R, Cheang MC, Martin L-A, Dowsett M. Acquired ESR1 mutation and persistent expression of estrogen regulated genes in ER+ breast cancers on long-term neoadjuvant treatment with aromatase inhibitors [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-15-01.

Abstract P2-02-01: Withdrawn

This abstract was withdrawn by the authors.

Biomarker changes associated with the development of resistance to aromatase inhibitors (AIs) in estrogen receptor-positive breast cancer

BACKGROUND

The purpose of this study was to identify any differences in key biomarkers associated with estrogen action between biopsies taken at diagnosis and at recurrence or progression during treatment with an aromatase inhibitor (AI).

PATIENTS AND METHODS

Patients were retrospectively identified from a clinical database as having relapsed or progressed during AI treatment. Immunohistochemistry was carried out against estrogen receptor (ER), progesterone receptor (PgR), human epidermal growth factor receptor 2 (HER2), insulin-like growth factor type-1 receptor (IGF1R), insulin receptor substrate-1 (IRS-1), stathmin, phosphatase and tensin homolog and Ki67.

RESULTS

Fifty-five pairs of samples were identified with ER- and/or PgR-positive diseases. Four (7%) patients were ER-negative at progression. Overall, PgR levels were lower in the recurrence sample, but 35% of cases remained positive. IGF1R levels decreased significantly. There were no substantial changes in HER2, IRS-1 or stathmin levels to indicate a role in resistance. Higher Ki67 levels at resistance indicate more proliferative disease.

CONCLUSIONS

The phenotype of AI-recurrent lesions shows high between-tumour heterogeneity. There is evidence of an increase in Ki67, a reduction in IGF1R and a loss of ER expression in some individuals and some activation of growth factor signalling pathways that may explain resistance in individuals and merit treatment targeted to those pathways. Biopsy at recurrence will be necessary to identify the relevant target for individuals.

P2-12-01: Immunohistochemical (IHC) BAG1 Expression Improves the Estimation of Residual Risk (RR) by IHC4 in Postmenopausal Patients Treated with Anastrozole or Tamoxifen: A TransATAC Study

Aim: To determine whether the incorporation of BAG1 staining improves the estimate of RR after endocrine therapy in postmenopausal patients with ER+ve tumours treated with endocrine therapy. Background: BAG1 encodes a protein (BCL2-associated athanogene 1) that binds to BCL2 and enhances its anti-apoptotic effects. BAG1 is included as a separate subgroup in the 21-gene OncotypeDx Recurrence Score (RS) that is used to assess RR after endocrine therapy in primary ER+ breast cancer. IHC4 is a 4-panel set of IHC markers (ER, PgR, HER2, Ki67) that was shown to provide as much prognostic accuracy as RS in the translational arm of the ATAC trial (TransATAC) of anastrozole versus tamoxifen alone or combined and subsequently independently validated (Cuzick et al, JCO, 2011, in press). Addition of extra markers such as BAG1 to IHC4 may improve the accuracy of the IHC4 and provide extra discriminatory power for oncologists.

Methods: Samples in triplicate TMAs from the TransATAC cohort were stained for BAG1 using the Genetex 3.10G3E2 antibody after validation using siRNA knockdown. Staining was scored separately as nuclear or cytoplasmic and categorized by intensity as 0, 1, 2 or 3. BAG1 IHC values were assessed for their correlation with BAG1 mRNA levels. The statistical analysis plan was pre-specified and tested possible additional information from BAG1 expression to the IHC4 in patients not treated with chemotherapy by change in the likelihood ratio chi-square (ΔLR-X2). Results were included only if there was also complete data for ER, PgR, Ki67 and HER2. Primary analysis was on the HER2−ve node-negative (N-neg) population; secondary analysis was on all N-neg patients. Follow-up was to 10 years and the primary end-point was time to distant recurrence (TTDR).

Results: Data on both nuclear and cytoplasmic BAG1 as well as the other 4 IHC parameters was available on 961 cases of which 855 were HER2−ve. There was a significant correlation between cytoplasmic and nuclear BAG1 (p=0.23, p<0.0001) but the nuclear staining correlated better with mRNA levels and was therefore considered further. Weak but significant correlations were also seen with ER, PgR and tumour grade. In the univariate analysis nuclear BAG1 was significantly associated with worse TTDR in HER2−ve and all N-neg cases (X2=7.91, p=0.005 and X2=10.63, p=0.001 respectively). Nuclear BAG1 also contributed significantly in multivariate analyses in the 2 populations firstly when added to the clinical model (X2=4.99, p=0.02 and X2=5.93, p=0.015 respectively) and secondly when subtracted from clinical plus the IHC4 parameters (X2=5.55, p=0.02 and X2=4.50, p=0.03 respectively).

Conclusions: Nuclear BAG1 expression has significant value for estimating RR that is independent of standard clinical and IHC parameters and it improves the prediction of TTDR in the TransATAC population beyond that with the validated IHC4 score. Unlike IHC4 markers, BAG1 is not commonly measured in pathology work-up of breast cancers. The clinical utility of its addition to IHC4 will be tested by measuring its discrimination of high and low risk patients in clinical practice.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-12-01.

A Breast Cancer-Associated SNP Adjacent to ESR1 Correlates with Oestrogen Receptor-α (ERα) Level in Invasive Breast Tumours

Aim: To identify whether breast cancer-associated SNP rs2046210 is associated with ERα level in invasive breast tumours.BackgroundA recent genome-wide association study identified SNP rs2046210 at 6q25.1 as having a strong association with breast cancer risk1. The SNP is located 29kb upstream of the first untranslated exon of ESR1 and 180kb upstream of the transcription start site2. Rs2046210 is not in linkage disequilibrium (LD) with two of the most widely studied polymorphisms in ESR1. We test here the hypothesis that rs2046210 may be associated with altered ESR1 expression.MethodsPatients with both leukocyte DNA and invasive breast tumour paraffin blocks available were identified from two of our ongoing tissue collections: Femara Anastrazole Clinical Evaluation (FACE) and the British Breast Cancer (BBC) study. Germline DNA was extracted from bloods using the QIAamp DNA Blood Mini Kit. PCR was performed with primers spanning the SNP site, with a single basepair mismatch in the reverse sequence to generate an HhaI restriction site in the presence of the C allele. PCR product was run on a 3% agarose gel to confirm presence of a single 120bp band. Restriction digest with HhaI was then performed and products run on a 4% Metaphor agarose gel. Genotype was assigned as follows: 97bp band only = wild-type (C/C); 97bp and 120bp band = heterozygote (C/T); 120bp band only = variant (T/T). From corresponding invasive breast tumour, ERα was assessed on 4μm whole sections using clone 6F11 (Vector Labs) and quantified by H-score. Mean H-scores (left and right invasive breast tumours) were used for the BBC group. ERα- samples (H-score≤1.0) were excluded. Analysis was by ANOVA using non-parametric bias-corrected and accelerated 95% bootstrap confidence intervals (2000 replications), with genotype fitted as a score and study as a stratifying co-variate.ResultsH-score (mean) by genotypeStudyWild-typeHeterozygoteVariantFACE (n=280)171.8180.9184.9BBC (n=46)180.0178.9194.1Fitted mean172.6179.7186.7(% samples)(45)(44)(11) Minor allele frequency was 33%, which is similar to the 38% previously reported in patients of European ancestry1. Within FACE, increased ERα was seen with presence of variant SNP. In the BBC group, variant SNP patients had higher ERα than both wild-type and heterozygote. Overall, there was a significant difference in ERα score per genotype group of 7.05, (95% CI 0.7-13.5, p=0.035). This was circa 4% difference in H-score per variant allele.ConclusionThe variant genotype of SNP rs2046210 is associated with increased ERα expression. While the increase contributed by the variant allele is relatively modest, this may partly explain why the SNP is associated with increased breast cancer risk. Similar studies should be conducted in normal breast tissue.1Zheng et al. (2009) Nat. Gen. 41(3): 324-3282Kos et al. (2001) Mol. Endocrinol. 15: 2057-2063

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4138.