Clinical and pathological factors influencing survival in a large cohort of triple-negative breast cancer patients

Burden of Disease and Cost of Illness of Triple-Negative Breast Cancer in Portugal

BACKGROUND

Triple-negative breast cancer accounts for 15% of all breast cancer cases, and it has a lower survival rate and higher incidence of early recurrence, particularly during the first 10 years after diagnosis.

OBJECTIVE

This study aimed to estimate the cost and burden of triple-negative breast cancer among the female population in 2019 in Portugal from a societal perspective.

METHODS

The prevalence of triple-negative breast cancer was calculated using a cumulative incidence model on the basis of national epidemiological data. The burden of disease was expressed as disability-adjusted life years, including the years lost due to disability and years of life lost. Healthcare resource utilization was quantified with input from an expert panel, and costs were estimated on the basis of diagnosis-related groups. Indirect costs were established following the human capital approach and supported by inputs from an expert panel.

RESULTS

Considering a prevalence of 7052 cases of triple-negative breast cancer in 2019, the expert panel confirmed that approximately 24%, 29%, 28% and 19% of the patients were in stages I, II, III and IV, respectively. The burden of this disease in Portugal was estimated at 22,566 disability-adjusted life years per year, 94% of which resulted from premature deaths. The total annual cost was equal to €50,351,934, with direct and indirect costs representing 56% and 44%, respectively. The average cost per patient with triple-negative breast cancer was €7140. Direct costs accounted for €28 million and were associated mainly with triple-negative breast cancer locoregional stage treatment and follow-up (65%). Indirect costs represented €22 million and were largely linked to withdrawal from the job market (94%).

CONCLUSION

Triple-negative breast cancer is an impactful disease with high humanistic and economic costs at the national level. The high mortality and low survival rates of this subtype mean that most disability-adjusted life years are due to years of life lost rather than years lost due to disability. Its prevalence is greater among women aged 45-49 years, suggesting a considerable burden regarding labour absenteeism and withdrawal from the job market.

Early detection of triple-negative breast cancer: evidence of a favourable prognostic impact in a comparative analysis of screen-detected versus symptomatic cases

PURPOSE

Mammographic screening is effective in reducing breast cancer mortality, but the impact of screening on triple-negative breast cancers (TNBCs) outcomes remains debated. This study aims to determine if screen detection is an independent prognostic factor for TNBCs and to analyse the radiological and pathological differences between screen-detected and symptomatic TNBCs.

METHODS

This retrospective cohort study analysed 353 histologically confirmed TNBC cases diagnosed between 2013 and 2020 at a single institution in Turin, Italy. Cases were categorized into screen-detected and symptomatic groups based on initial presentation. Clinical, radiological and pathological characteristics as well as disease-free survival (DFS) and overall survival (OS) were compared between groups. Statistical analyses included Kaplan-Meier survival curves and Cox proportional hazard models, adjusting for several clinical and biological variables.

RESULTS

50.1% of cases were screen-detected and 49.9% were symptomatic. Screen-detected cases were more commonly smaller (T1 or T2) (96.6%) than symptomatic cases (75%) (p < 0.001). Also, compared to symptomatic tumours, screen-detected ones were more often node negative (62.4% vs. 48%, p = 0.007) and diagnosed at a lower stage (85.4% vs. 63.8%, p < 0.001), with better DFS and OS. Detection method was not an independent prognostic factor, while stage at diagnosis, vascular invasion, histologic type and tumour-infiltrating lymphocytes (TILS) were more significant predictors of prognosis. Radiological and biological features were similar between the two groups.

CONCLUSIONS

TNBCs correlate with favourable pathological features and improved survival outcomes in univariate analyses, but these benefits diminish when accounting for traditional prognostic factors. Hence, the better prognosis observed among screen-detected cases is more likely due to stage shift rather than tumour biology.

Harnessing Artificial Intelligence for Precision Diagnosis and Treatment of Triple Negative Breast Cancer

Triple-Negative Breast Cancer (TNBC) is a highly aggressive subtype of breast cancer (BC) characterized by the absence of estrogen, progesterone, and HER2 receptors, resulting in limited therapeutic options. This article critically examines the role of Artificial Intelligence (AI) in enhancing the diagnosis and treatment of TNBC treatment. We begin by discussing the incidence of TNBC and the fundamentals of precision medicine, emphasizing the need for innovative diagnostic and therapeutic approaches. Current diagnostic methods, including conventional imaging techniques and histopathological assessments, exhibit limitations such as delayed diagnosis and interpretative discrepancies. This article highlights AI-driven advancements in image analysis, biomarker discovery, and the integration of multi-omics data, leading to enhanced precision and efficiency in diagnosis and treatment. In treatment, AI facilitates personalized therapeutic strategies, accelerates drug discovery, and enables real-time monitoring of patient responses. However, challenges persist, including issues related to data quality, model interpretability, and the societal impact of AI implementation. In the conclusion, we discuss the future prospects of integrating AI into clinical practice and emphasize the importance of multidisciplinary collaboration. This review aims to outline key trends and provide recommendations for utilizing AI to improve TNBC management outcomes, while highlighting the need for further research.

Serum Lactate Dehydrogenase Levels: The Grim Reaper Sign in Acute Pancreatitis?

Background and aims

Acute pancreatitis (AP) frequently presents in emergency departments and poses challenges in predicting severity and mortality. Established scoring systems like Ranson criteria, Acute Physiology And Chronic Health Evaluation II (APACHE) II, and Bedside Index of Severity in Acute Pancreatitis (BISAP) have varying effectiveness. Lactate dehydrogenase (LDH), an enzyme released during tissue damage, shows promise as a marker for organ injury in AP. This study aimed to evaluate LDH's potential to predict mortality risk and hospital stay duration in AP patients.

Methods

A retrospective cohort study analyzed AP cases at HCA Healthcare facilities from January 2011 to January 2021. Among 514 patients with LDH data at admission, groups were categorized based on LDH levels. Outcomes included hospital and ICU stay lengths, mortality rates, and factors such as age, gender, race, BMI, and medical history.

Results

Patients were stratified into three groups: Group 1 (<300 IU/L), Group 2 (300-600 IU/L), and Group 3 (>600 IU/L) based onLDHlevels. Patients withLDH>600 IU/L experienced an average hospital stay extension of 4.5 days,were 3.2 times more likely to require ICU admission, and faced a 12.1 times higher mortality risk compared to those with LDH <300 IU/L.

Conclusion

This study highlights LDH as a potentially valuable predictor of hospital stay duration, ICU requirements, and mortality rates in AP patients. Its cost-effectiveness and accessibility suggest LDH testing could aid clinical decision-making in AP management. Future prospective studies should further explore LDH's role in optimizing AP patient care.

Prognostic predictive value of Ki-67 in stage I-II triple-negative breast cancer

Aim: Our research aimed to determine an optimal cutoff value and investigate the prognostic predictive function of Ki-67. Materials & methods: We retrospectively enrolled 1146 patients diagnosed with stage I-II triple-negative breast cancer. Disease-free and overall survival were analyzed using the Kaplan-Meier method and the Cox regression model. Results: We classified Ki-67 >45% as the high group (n = 716). A Ki-67 level of >45% was associated with poorer disease-free survival (p = 0.039) and overall survival (p = 0.029). Lymph node stage, neoadjuvant chemotherapy, and radiotherapy were independent predictive variables of prognosis. Conclusion: Triple-negative breast cancer may be further subcategorized according to the Ki-67 level. Neoadjuvant chemotherapy and postoperative radiotherapy can improve the prognosis of early triple-negative breast cancer.

Identification of CD160-TM as a tumor target on triple negative breast cancers: possible therapeutic applications

BACKGROUND

Despite major therapeutic advances, triple-negative breast cancer (TNBC) still presents a worth prognosis than hormone receptors-positive breast cancers. One major issue relies in the molecular and mutational heterogeneity of TNBC subtypes that is reinforced by the absence of reliable tumor-antigen that could serve as a specific target to further promote efficient tumor cell recognition and depletion. CD160 is a receptor mainly expressed by NK lymphocytes and presenting two isoforms, namely the GPI-anchored form (CD160-GPI) and the transmembrane isoform (CD160-TM). While CD160-GPI is constitutively expressed on resting cells and involved in the generation of NK cells' cytotoxic activity, CD160-TM is neo-synthesized upon activation and promotes the amplification of NK cells' killing ability.

METHODS

CD160 expression was assessed by immunohistochemistry (IHC) and flow cytometry on TNBC patient biopsies or cell lines, respectively. Antibody (Ab)-mediated tumor depletion was tested in vitro by performing antibody-dependent cell cytotoxicity (ADCC) and phagocytosis (ADCP) assays, and in vivo on a TNBC mouse model.

RESULTS

Preliminary data obtained by IHC on TNBC patients' tumor biopsies revealed an unconventional expression of CD160 by TNBC tumor cells. By using a specific but conformation-dependent anti-CD160-TM Ab, we established that CD160-TM, but not CD160-GPI, was expressed by TNBC tumor cells. A conformation-independent anti-CD160-TM mAb (22B12; muIgG2a isotype) was generated and selected according to pre-defined specificity and functional criterions. In vitro functional assays demonstrated that ADCC and ADCP could be induced in the presence of 22B12, resulting in TNBC cell line apoptosis. The ability of 22B12 to exert an in vivo anti-tumor activity was also demonstrated on a TNBC murine model.

CONCLUSIONS

Our data identify CD160-TM as a tumor marker for TNBC and provide a rational for the use of anti-CD160-TM antibodies as therapeutic tools in this tumor context.

The oncogenic miR-429 promotes triple-negative breast cancer progression by degrading DLC1

Lines of evidence have demonstrated that the oncogenic miRNAs are pivotal to the progression of breast cancer. In this study, we investigated the biological traits of microRNA-429 (miR-429) in triple-negative breast cancer (TNBC) and the underlying molecular mechanism. We found that miR-429 was notably overexpressed in TNBC, and promoted TNBC cell proliferation, migration, and invasion by degrading the tumor suppressor DLC1. In conclusion, our findings reveal the mechanism of tumorigenic miR-429 in TNBC, which paves the way for target therapies translation in clinical settings.

Neoadjuvant chemotherapy response, disease-free survival, and overall survival of breast cancer in a single institution

Background

Breast cancer is the most common malignancy among women worldwide. Previous studies have shown factors influencing breast cancer patients' survival, including histopathological grading, stage, histopathological type, hormone receptors, and the number of mitotic images. This study aimed to determine the survival rate in breast cancer patients based on neoadjuvant chemotherapy (NAC) response and regimen.

Methods

This was an observational analytic study with a retrospective design. The population was breast cancer patients at our institution who had undergone NAC. Kaplan-Meier analysis using the log-rank method was used to determine the level of survivability (overall survival [OS] and disease-free survival [DFS]) of patients based on chemotherapy response and regimen.

Results

The NAC overall response rate of breast cancer patients was 93.17 %, whereas the non-response rate was 6.83 %. Significant differences existed in the DFS of patients by chemotherapy response (p = 0.010). Patients with a complete response had a mean survival of 71.37 ± 2.92 months, those with progressive disease had a mean survival of 64.80 ± 15.58 months, and overall patients had a mean survival of 68.56 ± 10.452 months. Patients with a complete response had a mean recurrence time of 69.54 ± 7.48 months; this was 57.53 ± 19.06 months in those with progressive disease, for an overall time of 65.41 ± 13.81 months. No significant difference existed between the NAC regimens in OS and DFS (p = 0.901 and p = 0.798, respectively).

Conclusion

Generally, the response to NAC in breast cancer was very good. The DFS rates were significantly different from the chemotherapy response but not from the NAC regimen.

Prediction of Axillary Lymph Node Metastasis in Early-stage Triple-Negative Breast Cancer Using Multiparametric and Radiomic Features of Breast MRI

RATIONALE AND OBJECTIVES

To investigate whether machine learning (ML) approaches using breast magnetic resonance imaging (MRI)-derived multiparametric and radiomic features could predict axillary lymph node metastasis (ALNM) in stage I-II triple-negative breast cancer (TNBC).

MATERIALS AND METHODS

Between 2013 and 2019, 86 consecutive patients with TNBC who underwent preoperative MRI and surgery were enrolled and divided into ALNM (N = 27) and non-ALNM (n = 59) groups according to histopathologic results. For multiparametric features, kinetic features using computer-aided diagnosis (CAD), morphologic features, and apparent diffusion coefficient (ADC) values at diffusion-weighted images were evaluated. For extracting radiomic features, three-dimensional segmentation of tumors using T2-weighted images (T2WI) and T1-weighted subtraction images were respectively performed by two radiologists. Each predictive model using three ML algorithms was built using multiparametric features or radiomic features, or both. The diagnostic performances of models were compared using the DeLong method.

RESULTS

Among multiparametric features, non-circumscribed margin, peritumoral edema, larger tumor size, and larger angio-volume at CAD were associated with ALNM in univariate analysis. In multivariate analysis, larger angio-volume was the sole statistically significant predictor for ALNM (odds ratio = 1.33, P = 0.008). Regarding ADC values, there were no significant differences according to ALNM status. The area under the receiver operating characteristic curve for predicting ALNM was 0.74 using multiparametric features, 0.77 using radiomic features from T1-weighted subtraction images, 0.80 using radiomic features from T2WI, and 0.82 using all features.

CONCLUSION

A predictive model incorporating breast MRI-derived multiparametric and radiomic features may be valuable in predicting ALNM preoperatively in patients with TNBC.

Prognostic value of tumor necrosis based on the evaluation of frequency in invasive breast cancer

BACKGROUND

Tumor necrosis (TN) was associated with poor prognosis. However, the traditional classification of TN ignored spatial intratumor heterogeneity, which may be associated with important prognosis. The purpose of this study was to propose a new method to reveal the hidden prognostic value of spatial heterogeneity of TN in invasive breast cancer (IBC).

METHODS

Multiphoton microscopy (MPM) was used to obtain multiphoton images from 471 patients. According to the relative spatial positions of TN, tumor cells, collagen fibers and myoepithelium, four spatial heterogeneities of TN (TN1-4) were defined. Based on the frequency of individual TN, TN-score was obtained to investigate the prognostic value of TN.

RESULTS

Patients with high-risk TN had worse 5-year disease-free survival (DFS) than patients with no necrosis (32.5% vs. 64.7%; P < 0.0001 in training set; 45.8% vs. 70.8%; P = 0.017 in validation set), while patients with low-risk TN had a 5-year DFS comparable to patients with no necrosis (60.0% vs. 64.7%; P = 0.497 in training set; 59.8% vs. 70.8%; P = 0.121 in validation set). Furthermore, high-risk TN "up-staged" the patients with IBC. Patients with high-risk TN and stage I tumors had a 5-year DFS comparable to patients with stage II tumors (55.6% vs. 62.0%; P = 0.565 in training set; 62.5% vs. 66.3%; P = 0.856 in validation set), as well as patients with high-risk TN and stage II tumors had a 5-year DFS comparable to patients with stage III tumors (33.3% vs. 24.6%; P = 0.271 in training set; 44.4% vs. 39.3%; P = 0.519 in validation set).

CONCLUSIONS

TN-score was an independent prognostic factor for 5-year DFS. Only high-risk TN was associated with poor prognosis. High-risk TN "up-staged" the patients with IBC. Incorporating TN-score into staging category could improve its performance to stratify patients.

Prognosis of Patients With Triple-negative Breast Cancer: A Population-based Study From SEER Database

BACKGROUND

Triple-negative breast cancer (TNBC) was a particularly aggressive subtype of breast cancer associated with poor prognosis. This retrospective study was conducted to investigate the clinical features, prognostic factors, and benefits of surgery of patients with TNBC.

METHODS

From 2010 to 2015, 33654 female patients with TNBC were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. The patients were randomly divided into the training and validation cohorts. Univariate and multivariable cox regression were performed to identify prognostic factors, based on which a nomogram was constructed. Validation of the nomogram was assessed by concordance index (c-index) and calibration curves. Survival curves were plotted according to metastatic burdens and risk groups differentiated by nomogram.

RESULTS

Patients of younger age (<65 years old), white race, married status, lower grade, lower TNM stage and primary tumor surgery tended to have better outcome. The C-index and calibration curves displayed high discrimination in the training and validation sets (C-index 0.794 and 0.793, respectively), indicating suitable external performance of the nomogram model. Patients of bone-only metastases as well as bone and liver metastases showed superior cancer-specific survival (CSS) time if surgery of primary tumor was performed. Besides, patients of all risk groups showed better CSS when receiving surgery.

CONCLUSION

This study provided population-based prognostic analysis in patients with TNBC and constructed a predicting nomogram with a robust discrimination. The findings of potential benefit of surgery to CSS would shed some lights on the treatment tactics of patients with TNBC.

Comparative analysis of clinicopathological characteristics of central necrotizing breast cancer and basal cell-like breast cancer

Purpose

This study aims to compare the clinicopathological and immunohistochemical characteristics of centrally necrotizing carcinoma of the breast (CNC) and basal-like breast cancer (BLBC), as well as to analyze the characteristics of the molecular typing of the CNC.

Methods

The clinicopathological features of 69 cases of CNC and 48 cases of BLBC were observed and compared. EnVision immunohistochemical staining was performed to detect the expressions of hypoxia-inducible factor 1α (HIF-1α), breast cancer susceptibility gene 1 (BRCA1), and vascular endothelial growth factor (VEGF) in CNC and BLBC.

Results

The age of the 69 patients ranged from 32 to 80 years, with an average of 54.55 years. Gross examination showed that most tumors were well-defined single central nodules with a diameter of 1.2~5.0 cm. Microscopically, there is a large necrotic or acellular area in the center of the tumor, mainly composed of tumor coagulative necrosis with varying degrees of fibrosis or hyaline degeneration. A small amount of cancer tissue remained in the form of a ribbon or small nest around the necrotic focus. Among 69 cases of CNC, the proportion of basal cell type (56.5%) was significantly higher than that of lumen type A (18.84%), lumen type B (13.04%), HER2 overexpression (5.8%), and nonexpression (5.8%). A total of 31 cases were followed up for 8~50 months, with an average of 33.94 months. There have been nine cases of disease progression. When compared to BLBC, there were no significant differences in BRCA1 and VEGF protein expression in response to CNC (p &gt; 0.05), but there were significant differences in protein expression in HIF-1α (p &lt; 0.05).

Conclusion

The molecular typing of CNC showed that over half of those were BLBC. No statistically significant difference in the expression of BRCA1 was observed between CNC and BLBC; thus, we predict that targeted therapy for BRCA1 in BLBC may also have considerable effects in CNC patients. The expression of HIF-1α is significantly different in CNC and BLBC, and perhaps HIF-1α can be used as a new entry point to distinguish between the two. There is a significant correlation between the expression of VEGF and HIF-1α in BLBC, and there was no significant correlation between the expression levels of the two proteins in CNC.

Nomogram for predicting overall survival in Chinese triple-negative breast cancer patients after surgery

BACKGROUND

There are few nomograms for the prognosis of Chinese patients with triple-negative breast cancer (TNBC).

AIM

To construct and validate a nomogram for overall survival (OS) of Chinese TNBC patients after surgery.

METHODS

This study used the data of SEER*stat 8.3.5 and selected Chinese patients with TNBC operated on between 2010 and 2015. Univariate and multivariate Cox proportional hazard regression models were used. The identified variables were integrated to form a predictive nomogram and risk stratification model; it was assessed with C-indexes and calibration curves.

RESULTS

The median and maximal OS of the 336 patients was 39 and 83 mo, respectively. The multivariate analysis showed that age (P = 0.043), marital status (P = 0.040), tumor localization (P = 0.030), grade (P = 0.035), T classification (P = 0.012), and N classification (P = 0.002) were independent prognostic factors. The six variables were combined to construct a 1-, 3- and 5-year OS nomogram. The C-indexes of the nomogram to predict OS were 0.766 and compared to the seventh edition staging system, which was higher (0.766 vs 0.707, P < 0.001). In order to categorize patients into different prognostic groups, a risk stratification model was created. There was a significant difference between the Kaplan-Meier curves of the entire cohort and each disease stage according to the nomogram.

CONCLUSION

The nomogram provided prognostic superiority over the traditional tumor, node and metastasis system. It could help clinicians make individual OS or risk predictions for Chinese TNBC patients after surgery.

Deciphering clinical significance of BCL11A isoforms and protein expression roles in triple-negative breast cancer subtype

Purpose

Triple negative breast cancer (TNBC) is an aggressive clinical tumor, accounting for about 25% of breast cancer (BC) related deaths. Chemotherapy is the only therapeutic option to treat TNBC, hence a detailed understanding of the biology and its categorization is required. To investigate the clinical relevance of BCL11A in TNBC subtype, we focused on gene and protein expression and its mutational status in a large cohort of this molecular subtype.

Methods

Gene expression profiling of BCL11A and its isoforms (BCL11A-XL, BCL11A-L and BCL11A-S) has been determined in Luminal A, Luminal B, HER2-enriched and TNBC subtypes. BCL11A protein expression has been analyzed by immunohistochemistry (IHC) and its mutational status by Sanger sequencing.

Results

In our study, BCL11A was significantly overexpressed in TNBC both at transcriptional and translational levels compared to other BC molecular subtypes. A total of 404 TNBCs were selected and examined showing a high prevalence of BCL11A-XL (37.3%) and BCL11A-L (31.4%) isoform expression in TNBC, associated with a 26% of BCL11A protein expression levels. BCL11A protein expression predicts scarce LIV (HR = 0.52; 95% CI, 0.29–0.92, P = 0.03) and AR downregulation (HR = 0.37; 95% CI, 0.16–0.88; P = 0.02), as well as a higher proliferative index in TNBC cells. BCL11A-L expression is associated with more aggressive TNBC histological types, such as medullary and metaplastic carcinoma.

Conclusion

Our finding showed that BCL11A protein expression acts as an unfavorable prognostic factor in TNBC patients, especially in non luminal TNBCs subgroups. These results may yield a better treatment strategy by providing a new parameter for TNBC classification.

Interleukin-3-Receptor-α in Triple-Negative Breast Cancer (TNBC): An Additional Novel Biomarker of TNBC Aggressiveness and a Therapeutic Target

Simple Summary

Molecular and histological profiling is crucial for biomarker and therapeutic target discovery, for example, in TNBC. We demonstrated that IL-3Rα expression led to the identification of a subgroup of TNBC patients displaying a poor overall survival. Moreover, we refined TNBC molecular annotation and drew a model including IL-3Rα, PD-L1, and genes related to EMT, which finely discriminates cancer aggressiveness. Finally, we first demonstrated that IL-3Rα is instrumental in granting tumour adaptation and progression by reprogramming TNBC cells to form large dysfunctional vessels and reshaping PD-L1 expression in primary tumours and metastases. Therefore, the IL-3/IL-3Rα axis may be proposed as a marker of TNBC aggressiveness, as a novel TNBC therapeutic challenge.

Abstract

Tumour molecular annotation is mandatory for biomarker discovery and personalised approaches, particularly in triple-negative breast cancer (TNBC) lacking effective treatment options. In this study, the interleukin-3 receptor α (IL-3Rα) was investigated as a prognostic biomarker and therapeutic target in TNBC. IL-3Rα expression and patients’ clinical and pathological features were retrospectively analysed in 421 TNBC patients. IL-3Rα was expressed in 69% human TNBC samples, and its expression was associated with nodal metastases (p = 0.026) and poor overall survival (hazard ratio = 1.50; 95% CI = 1.01–2.2; p = 0.04). The bioinformatics analysis on the Breast Invasive Carcinoma dataset of The Cancer Genome Atlas (TCGA) proved that IL-3Rα was highly expressed in TNBC compared with luminal breast cancers (p = 0.017, padj = 0.026). Functional studies demonstrated that IL-3Rα activation induced epithelial-to-endothelial and epithelial-to-mesenchymal transition, promoted large blood lacunae and lung metastasis formation, and increased programmed-cell death ligand-1 (PD-L1) in primary tumours and metastases. Based on the TCGA data, IL-3Rα, PD-L1, and EMT coding genes were proposed to discriminate against TNBC aggressiveness (AUC = 0.86 95% CI = 0.82–0.89). Overall, this study identified IL-3Rα as an additional novel biomarker of TNBC aggressiveness and provided the rationale to further investigate its relevance as a therapeutic target.

Survival outcome assessment for triple-negative breast cancer: a nomogram analysis based on integrated clinicopathological, sonographic, and mammographic characteristics

Objective

This study aimed to incorporate clinicopathological, sonographic, and mammographic characteristics to construct and validate a nomogram model for predicting disease-free survival (DFS) in patients with triple-negative breast cancer (TNBC).

Methods

Patients diagnosed with TNBC at our institution between 2011 and 2015 were retrospectively evaluated. A nomogram model was generated based on clinicopathological, sonographic, and mammographic variables that were associated with 1-, 3-, and 5-year DFS determined by multivariate logistic regression analysis in the training set. The nomogram model was validated according to the concordance index (C-index) and calibration curves in the validation set.

Results

A total of 636 TNBC patients were enrolled and divided into training cohort (n = 446) and validation cohort (n = 190). Clinical factors including tumor size > 2 cm, axillary dissection, presence of LVI, and sonographic features such as angular/spiculated margins, posterior acoustic shadows, and presence of suspicious lymph nodes on preoperative US showed a tendency towards worse DFS. The multivariate analysis showed that no adjuvant chemotherapy (HR = 6.7, 95% CI: 2.6, 17.5, p < 0.0005), higher axillary tumor burden (HR = 2.7, 95% CI: 1.0, 7.1, p = 0.045), and ≥ 3 malignant features on ultrasound (HR = 2.4, CI: 1.1, 5.0, p = 0.021) were identified as independent prognostic factors associated with poorer DFS outcomes. In the nomogram, the C-index was 0.693 for the training cohort and 0.694 for the validation cohort. The calibration plots also exhibited excellent consistency between the nomogram-predicted and actual survival probabilities in both the training and validation cohorts.

Conclusions

Clinical variables and sonographic features were correlated with the prognosis of TNBCs. The nomogram model based on three variables including no adjuvant chemotherapy, higher axillary tumor load, and more malignant sonographic features showed good predictive performance for poor survival outcomes of TNBC.

Key Points

• The absence of adjuvant chemotherapy, heavy axillary tumor load, and malignant-like sonographic features can predict DFS in patients with TNBC.

• Mammographic features of TNBC could not predict the survival outcomes of patients with TNBC.

• The nomogram integrating clinicopathological and sonographic characteristics is a reliable predictive model for the prognostic outcome of TNBC.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-022-08910-4.

Gini's mean difference and the long-term prognostic value of nodal quanta classes after pre-operative chemotherapy in advanced breast cancer

Gini's mean difference (GMD, mean absolute difference between any two distinct quantities) of the restricted mean survival times (RMSTs, expectation of life at a given time limit) has been proposed as a new metric where higher GMD indicates better prognostic value. GMD is applied to the RMSTs at 25 years time-horizon to evaluate the long-term overall survival of women with breast cancer who received neoadjuvant chemotherapy, comparing a classification based on the number (pN) versus a classification based on the ratio (LNRc) of positive nodes found at axillary surgery. A total of 233 patients treated in 1980-2009 with documented number of positive nodes (npos) and number of nodes examined (ntot) were identified. The numbers were categorized into pN0, npos = 0; pN1, npos = [1,3]; pN2, npos = [4,9]; pN3, npos ≥ 10. The ratios npnx = npos/ntot were categorized into Lnr0, npnx = 0; Lnr1, npnx = (0,0.20]; Lnr2, npnx = (0.20,0.65]; Lnr3, npnx > 0.65. The GMD for pN-classification was 5.5 (standard error: ± 0.9) years, not much improved over a simple node-negative vs. node-positive that showed a GMD of 5.0 (± 1.4) years. The GMD for LNRc-classification was larger, 6.7 (± 0.8) years. Among other conventional metrics, Cox-model LNRc's c-index was 0.668 vs. pN's c = 0.641, indicating commensurate superiority of LNRc-classification. The usability of GMD-RMSTs warrants further investigation.

Prognostic Value of Metabolic, Volumetric and Textural Parameters of Baseline [18F]FDG PET/CT in Early Triple-Negative Breast Cancer

Simple Summary

The aim of this study was to evaluate PET/CT parameters to determine different prognostic groups in TNBC, in order to select patients with a high risk of relapse, for whom therapeutic escalation can be considered. We have demonstrated that the MTV, TLG and entropy of the primary breast lesion could be of interest to predict the prognostic outcome of TNBC patients.

Abstract

(1) Background: triple-negative breast cancer (TNBC) remains a clinical and therapeutic challenge primarily affecting young women with poor prognosis. TNBC is currently treated as a single entity but presents a very diverse profile in terms of prognosis and response to treatment. Positron emission tomography/computed tomography (PET/CT) with ¹⁸F-fluorodeoxyglucose ([¹⁸F]FDG) is gaining importance for the staging of breast cancers. TNBCs often show high [¹⁸F]FDG uptake and some studies have suggested a prognostic value for metabolic and volumetric parameters, but no study to our knowledge has examined textural features in TNBC. The objective of this study was to evaluate the association between metabolic, volumetric and textural parameters measured at the initial [¹⁸F]FDG PET/CT and disease-free survival (DFS) and overall survival (OS) in patients with nonmetastatic TBNC. (2) Methods: all consecutive nonmetastatic TNBC patients who underwent a [¹⁸F]FDG PET/CT examination upon diagnosis between 2012 and 2018 were retrospectively included. The metabolic and volumetric parameters (SUV_max, SUV_mean, SUV_peak, MTV, and TLG) and the textural features (entropy, homogeneity, SRE, LRE, LGZE, and HGZE) of the primary tumor were collected. (3) Results: 111 patients were enrolled (median follow-up: 53.6 months). In the univariate analysis, high TLG, MTV and entropy values of the primary tumor were associated with lower DFS (p = 0.008, p = 0.006 and p = 0.025, respectively) and lower OS (p = 0.002, p = 0.001 and p = 0.046, respectively). The discriminating thresholds for two-year DFS were calculated as 7.5 for MTV, 55.8 for TLG and 2.6 for entropy. The discriminating thresholds for two-year OS were calculated as 9.3 for MTV, 57.4 for TLG and 2.67 for entropy. In the multivariate analysis, lymph node involvement in PET/CT was associated with lower DFS (p = 0.036), and the high MTV of the primary tumor was correlated with lower OS (p = 0.014). (4) Conclusions: textural features associated with metabolic and volumetric parameters of baseline [¹⁸F]FDG PET/CT have a prognostic value for identifying high-relapse-risk groups in early TNBC patients.

Prognostic Role of Androgen Receptor Expression in HER2+ Breast Carcinoma Subtypes

HER2+ breast cancer (BC) is an aggressive subtype representing a genetically and biologically heterogeneous group of tumors resulting in variable prognosis and treatment response to HER2-targeted therapies according to estrogen (ER) and progesterone receptor (PR) expression. The relationship with androgen receptors (AR), a member of the steroid hormone's family, is unwell known in BC. The present study aims to evaluate the prognostic impact of AR expression in HER2+ BC subtypes. A total of 695 BCs were selected and reviewed, AR, ER, PR and HER2 expression in tumor cells were examined by immunohistochemical method, and the SISH method was used in case of HER2 with equivocal immunohistochemical score (2+). A high prevalence of AR expression (91.5%) in BC HER+ was observed, with minimal differences between luminal and non-luminal tumor. According to steroid receptor expression, tumors were classified in four subgroups, including BC luminal and non-luminal HER2+ expressing or not AR. The luminal BC HER2 + AR+ was associated with lower histological grade, lower tumor size, higher PR expression and lower HER2 intensity of expression (2+). Also, the non-luminal tumors AR+ showed lower tumor size and lower prognostic stage but frequently higher grade and higher HER2 intensity of expression (3+). These findings should suggest a different progression of luminal and non-luminal tumors, both expressing AR, and allow us to speculate that the molecular mechanisms of AR, involved in the biology of BC HER2 + AR+, differ in relation to ER and PR expression. Moreover, AR expression may be a useful predictor of prognosis for overall survival (OS) in HER2+ BC subtypes. Our findings suggest that AR expression evaluation in clinical practice could be utilized in clinical oncology to establish different aggressiveness in BC HER2+ subtypes.

Radiomics features based on automatic segmented MRI images: Prognostic biomarkers for triple-negative breast cancer treated with neoadjuvant chemotherapy

PURPOSE

To establish radiomics prediction models based on automatic segmented magnetic resonance imaging (MRI) for predicting the systemic recurrence of triple-negative breast cancer (TNBC) in patients after neoadjuvant chemotherapy (NAC).

MATERIALS AND METHODS

A total of 147 patients with TNBC who underwent NAC between January 2009 and December 2018 were enrolled in this study. Clinicopathologic data were collected, and the differences between the recurrent and nonrecurrent patients were analyzed by univariate and multivariate analyses. Patients were randomly divided into training and testing sets. The training set consisted of 104 patients (recurrence: 22, nonrecurrence: 82), and the testing set consisted of 43 patients (recurrence: 9, nonrecurrence: 34). To establish the radiomics prediction model, we used a deep learning segmentation model to automatically segment tumor areas on dynamiccontrast-enhanced-MRI images of pre- and post-NAC magnetic resonance examinations. Radiomics features were then extracted from the tumor areas. Three MRI radiomics models were developed in the training set: a radiomics model based on pre-NAC MRI features (model 1), a radiomics model based on post-NAC MRI features (model 2), and a radiomics model based on both pre- and post-NAC MRI features (model 3). A clinical model for predicting systemic recurrence was built in the training set using independent clinical prediction factors. Receiver operating characteristic curve analysis was used to evaluate the performance of the radiomics and clinical models.

RESULTS

The clinical model yielded areas under the curve (AUCs) of 0.747 in the training set and 0.737 in the testing set in terms of predicting systemic recurrence. Models 1, 2, and 3 yielded AUCs of 0.879, 0.91, and 0.963 in the training set and 0.814, 0.802, and 0.933 in the testing set, respectively, in terms of predicting systemic recurrence. All of the radiomics models had achieved higher AUCs than the clinical model in the testing set. DeLong test was used to compare the AUCs between the models and indicated that the predictive performance of model 3 was better than the clinical model, and the difference was statistically significant (p < 0.05).

CONCLUSION

The radiomics models built based on the combination of pre- and post-NAC MRI features showed good performance in predicting whether patients with TNBC will have systemic recurrence within 3 years post-NAC. This can help us non-invasively identify which patients are at high risk of recurrence post-NAC, so that we can strengthen follow-up and treatment of these patients. Then the prognosis of these patients might be improved.

The value of prognostic ultrasound features of breast cancer in different molecular subtypes with a focus on triple negative disease

The ultrasound (US) features of breast cancer have recently been shown to have prognostic significance. We aim to assess these features according to molecular subtype. 1140 consecutive US visible invasive breast cancers had US size and mean stiffness by shearwave elastography (SWE) recorded prospectively. Skin thickening (> 2.5 mm) overlying the cancer on US and the presence of posterior echo enhancement were assessed retrospectively while blinded to outcomes. Cancers were classified as luminal, triple negative (TN) or HER2 + ve based on immunohistochemistry and florescent in-situ hybridization. The relationship between US parameters and breast cancer specific survival (BCSS) was ascertained using Kaplan–Meier survival curves and ROC analysis. At median follow-up 6.3 year, there were 117 breast cancer (10%) and 132 non-breast deaths (12%). US size was significantly associated with BCSS all groups (area under the curve (AUC) 0.74 in luminal cancers, 0.64 for TN and 0.65 for HER2 + ve cancers). US skin thickening was associated most strongly with poor prognosis in TN cancers (53% vs. 80% 6 year survival, p = 0.0004). Posterior echo enhancement was associated with a poor BCSS in TN cancers (63% vs. 82% 6 year survival, p = 0.02). Mean stiffness at SWE was prognostic in the luminal and HER2 positive groups (AUC 0.69 and 0.63, respectively). In the subgroup of patients with TN cancers receiving neo-adjuvant chemotherapy posterior enhancement and skin thickening were not associated with response. US skin thickening is a poor prognostic indicator is all 3 subtypes studied, while posterior enhancement was associated with poor outcome in TN cancers

Circulating tumor DNA is readily detectable among Ghanaian breast cancer patients supporting non-invasive cancer genomic studies in Africa

Circulating tumor DNA (ctDNA) sequencing studies could provide novel insights into the molecular pathology of cancer in sub-Saharan Africa. In 15 patient plasma samples collected at the time of diagnosis as part of the Ghana Breast Health Study and unselected for tumor grade and subtype, ctDNA was detected in a majority of patients based on whole- genome sequencing at high (30×) and low (0.1×) depths. Breast cancer driver copy number alterations were observed in the majority of patients.

Triple Negative Breast Cancer: A Mountain Yet to Be Scaled Despite the Triumphs

Metastatic progression and tumor recurrence pertaining to TNBC are certainly the leading cause of breast cancer-related mortality; however, the mechanisms underlying TNBC chemoresistance, metastasis, and tumor relapse remain somewhat ambiguous. TNBCs show 77% of the overall 4-year survival rate compared to other breast cancer subtypes (82.7 to 92.5%). TNBC is the most aggressive subtype of breast cancer, with chemotherapy being the major approved treatment strategy. Activation of ABC transporters and DNA damage response genes alongside an enrichment of cancer stem cells and metabolic reprogramming upon chemotherapy contribute to the selection of chemoresistant cells, majorly responsible for the failure of anti-chemotherapeutic regime. These selected chemoresistant cells further lead to distant metastasis and tumor relapse. The present review discusses the approved standard of care and targetable molecular mechanisms in chemoresistance and provides a comprehensive update regarding the recent advances in TNBC management.

A clinical calculator to predict disease outcomes in women with triple-negative breast cancer

PURPOSE

Triple-negative breast cancer (TNBC) is the most aggressive subtype of breast cancer, characterized by substantial risks of early disease recurrence and mortality. We constructed and validated clinical calculators for predicting recurrence-free survival (RFS) and overall survival (OS) for TNBC.

METHODS

Data from 605 women with centrally confirmed TNBC who underwent primary breast cancer surgery at Mayo Clinic during 1985-2012 were used to train risk models. Variables included age, menopausal status, tumor size, nodal status, Nottingham grade, surgery type, adjuvant radiation therapy, adjuvant chemotherapy, Ki67, stromal tumor-infiltrating lymphocytes (sTIL) score, and neutrophil-to-lymphocyte ratio (NLR). Final models were internally validated for calibration and discrimination using ten-fold cross-validation and compared with their base-model counterparts which include only tumor size and nodal status. Independent external validation was performed using data from 478 patients diagnosed with stage II/III invasive TNBC during 1986-1992 in the British Columbia Breast Cancer Outcomes Unit database.

RESULTS

Final RFS and OS models were well calibrated and associated with C-indices of 0.72 and 0.73, as compared with 0.64 and 0.62 of the base models (p < 0.001). In external validation, the discriminant ability of the final models was comparable to the base models (C-index: 0.59-0.61). The RFS model demonstrated greater accuracy than the base model both overall and within patient subgroups, but the advantages of the OS model were less profound.

CONCLUSIONS

This TNBC clinical calculator can be used to predict patient outcomes and may aid physician's communication with TNBC patients regarding their long-term disease outlook and planning treatment strategies.

Modulatory Role of microRNAs in Triple Negative Breast Cancer with Basal-Like Phenotype

Development of new research, classification, and therapeutic options are urgently required due to the fact that TNBC is a heterogeneous malignancy. The expression of high molecular weight cytokeratins identifies a biologically and clinically distinct subgroup of TNBCs with a basal-like phenotype, representing about 75% of TNBCs, while the remaining 25% includes all other intrinsic subtypes. The triple negative phenotype in basal-like breast cancer (BLBC) makes it unresponsive to endocrine therapy, i.e., tamoxifen, aromatase inhibitors, and/or anti-HER2-targeted therapies; for this reason, only chemotherapy can be considered an approach available for systemic treatment even if it shows poor prognosis. Therefore, treatment for these subgroups of patients is a strong challenge for oncologists due to disease heterogeneity and the absence of unambiguous molecular targets. Dysregulation of the cellular miRNAome has been related to huge cellular process deregulations underlying human malignancy. Consequently, epigenetics is a field of great promise in cancer research. Increasing evidence suggests that specific miRNA clusters/signatures might be of clinical utility in TNBCs with basal-like phenotype. The epigenetic mechanisms behind tumorigenesis enable progress in the treatment, diagnosis, and prevention of cancer. This review intends to summarize the epigenetic findings related to miRNAome in TNBCs with basal-like phenotype.

Tumor necrosis by pretreatment breast MRI: association with neoadjuvant systemic therapy (NAST) response in triple-negative breast cancer (TNBC)

PURPOSE

To determine if tumor necrosis by pretreatment breast MRI and its quantitative imaging characteristics are associated with response to NAST in TNBC.

METHODS

This retrospective study included 85 TNBC patients (mean age 51.8 ± 13 years) with MRI before NAST and definitive surgery during 2010-2018. Each MRI included T2-weighted, diffusion-weighted (DWI), and dynamic contrast-enhanced (DCE) imaging. For each index carcinoma, total tumor volume including necrosis (TTV), excluding necrosis (TV), and the necrosis-only volume (NV) were segmented on early-phase DCE subtractions and DWI images. NV and %NV were calculated. Percent enhancement on early and late phases of DCE and apparent diffusion coefficient were extracted from TTV, TV, and NV. Association between necrosis with pathological complete response (pCR) was assessed using odds ratio (OR). Multivariable analysis was used to evaluate the prognostic value of necrosis with T stage and nodal status at staging. Mann-Whitney U tests and area under the curve (AUC) were used to assess performance of imaging metrics for discriminating pCR vs non-pCR.

RESULTS

Of 39 patients (46%) with necrosis, 17 had pCR and 22 did not. Necrosis was not associated with pCR (OR, 0.995; 95% confidence interval [CI] 0.4-2.3) and was not an independent prognostic factor when combined with T stage and nodal status at staging (P = 0.46). None of the imaging metrics differed significantly between pCR and non-pCR in patients with necrosis (AUC < 0.6 and P > 0.40).

CONCLUSION

No significant association was found between necrosis by pretreatment MRI or the quantitative imaging characteristics of tumor necrosis and response to NAST in TNBC.

Meta-Analysis of Prevalence of Triple-Negative Breast Cancer and Its Clinical Features at Incidence in Indian Patients With Breast Cancer

PURPOSE

Breast cancer is the most common cancer in women in India, with higher incidence rates of aggressive subtypes, such as triple-negative breast cancer (TNBC).

METHODS

A systematic review was performed to compute pooled prevalence rates of TNBC among patients with breast cancer, and clinical features at presentation were systematically compared with non-TNBC in an Indian cohort of 20,000 patients.

RESULTS

Combined prevalence of TNBC among patients with breast cancer was found to be on the higher side (27%; 95% CI, 24% to 31%). We found that the estrogen receptor (ER) expression cutoff used to determine ER positivity had an influence on the pooled prevalence and ranged from 30% (ER/progesterone receptor [PR] cut ff at 1%) to 24% (ER/PR cutoff at 10%). Odds for TNBC to present in the younger age-group were significantly higher (pooled odds ratio [OR], 1.35; 95% CI, 1.08 to 1.69), with a significantly younger mean age of incidence (weighted mean difference, -2.75; 95% CI, -3.59 to -1.92). TNBC showed a significantly higher odds of presenting with high grade (pooled OR, 2.57; 95% CI, 2.12 to 3.12) and lymph node positivity (pooled OR, 1.39; 95% CI, 1.21 to 1.60) than non-TNBC.

CONCLUSION

Systematic review and meta-analysis of 34 studies revealed a high degree of heterogeneity in prevalence of TNBC within Indian patients with breast cancer, yet pooled prevalence of TNBC is high in India. High proportions of patients with TNBC present with aggressive features, such as high grade and lymph node positivity, compared with patients without TNBC. We emphasize the need for standardized methods for accurate diagnosis in countries like India.

Comparison of Nottingham Prognostic Index, PREDICT and PrognosTILs in Triple Negative Breast Cancer -a Retrospective Cohort Study

Triple-negative breast cancer (TNBC) represents a heterogenous subtype of breast cancer with generally poor prognosis. The prediction of its prognosis remains essential to clinicians in their therapeutical decision-making process. The aim of our study was to compare the validity of three multivariable analysis derived prognostic systems, the Nottingham Prognostic Index (NPI), PREDICT and PrognosTILs (a prognosticator including tumor infiltrating lymphocytes, TILs) in a series of TNBCs. Patients operated on with TNBC at the Department of Surgery, Bács-Kiskun County Teaching Hospital, Kecskemét between 2005 and 2016 were included. Clinical and pathological parameters and follow-up data were collected from medical charts. TILs were assessed retrospectively, following international recommendations. Estimated survivals of PrognosTILs, PREDICT and NPI were recorded and compared with real outcomes. Altogether 136 patients were included in this retrospective study. In univariate Cox analysis, type of surgery, pT, pN, stage, NPI and type of adjuvant therapy were the significant prognostic variables. The multivariate Cox-regression strengthened that NPI is an independent predictor of overall and disease-free survivals in TNBCs. The NPI, PREDICT and PrognosTILs could be compared directly only in a ROC curve analysis: the sensitivities and specificities of these predicting systems are rather similar with area under the curve values falling between 0.7 and 0.8, and NPI having the highest values. Our findings reflect the diverse prognosis of TNBC and highlight the difficulties of predicting its outcome. None of the three multivariable prognosticators is inferior to the others, the NPI can reliably be used for TNBCs.

Granular necrosis: a distinctive form of cell death in malignant tumours

Foci of necrosis are frequently seen in malignant tumours and may be due to a variety of causes. Different types of necrosis are given various names based upon their morphological features and presumed pathogenesis, such as coagulative, liquefactive and fibrinoid necrosis. Here, we propose the term 'granular necrosis' (GN) for a specific form of tumour necrosis characterised by the presence of well-defined necrotic foci being sharply demarcated from adjacent viable tumour. A constant feature is loss of architecture resulting in an amorphous necrotic mass containing granular nuclear and cytoplasmic debris, without an associated neutrophilic infiltrate. There is usually extensive karyorrhexis, which in larger tumours is more prominent at the periphery. These foci are often microscopic but may range up to several millimetres or larger in size. This distinctive form of necrosis has been erroneously given a variety of names in the literature including coagulative necrosis and microscopic necrosis, which on the basis of the aforementioned gross and microscopic findings is inappropriate. It is apparent that this is a specific form of necrosis, hence the descriptive term 'granular necrosis' that differentiates this form of necrosis from other types. The presence of GN is recognised as occurring in a variety of tumour types, being commonly seen in renal cell carcinoma, where it has been shown to have independent prognostic significance. In some epithelial and stromal tumours of the uterus, the presence of GN also has prognostic significance and is a defining feature for the differentiation of uterine leiomyoma and leiomyosarcoma. The pathogenesis of GN is unresolved. It does not show the features of apoptosis and in recent studies has been shown to have some of the molecular changes associated with necroptosis.

Histologic subtyping affecting outcome of triple negative breast cancer: a large Sardinian population-based analysis

BACKGROUND

Triple Negative breast cancer (TNBC) includes a heterogeneous group of tumors with different clinico-pathological features, molecular alterations and treatment responsivity. Our aim was to evaluate the clinico-pathological heterogeneity and prognostic significance of TNBC histologic variants, comparing "special types" to high-grade invasive breast carcinomas of no special type (IBC-NST).

METHODS

This study was performed on data obtained from TNBC Database, including pathological features and clinical records of 1009 TNBCs patients diagnosed between 1994 and 2015 in the four most important Oncology Units located in different hospitals in Sardinia, Italy. Kaplan-Meier analysis, log-rank test and multivariate Cox proportional-hazards regression were applied for overall survival (OS) and disease free survival (DFS) according to TNBC histologic types.

RESULTS

TNBC "special types" showed significant differences for several clinico-pathological features when compared to IBC-NST. We observed that in apocrine carcinomas as tumor size increased, the number of metastatic lymph nodes manifestly increased. Adenoid cystic carcinoma showed the smallest tumor size relative to IBC-NST. At five-year follow-up, OS was 92.1, 100.0, and 94.5% for patients with apocrine, adenoid cystic and medullary carcinoma, respectively; patients with lobular and metaplastic carcinoma showed the worst OS, with 79.7 and 84.3%, respectively. At ten-years, patients with adenoid cystic (100.0%) and medullary (94.5%) carcinoma showed a favourable prognosis, whereas patients with lobular carcinoma showed the worst prognosis (73.8%). TNBC medullary type was an independent prognostic factor for DFS compared to IBC-NST.

CONCLUSIONS

Our study confirms that an accurate and reliable histopathologic definition of TNBC subtypes has a significant clinical utility and is effective in the therapeutic decision-making process, with the aim to develop innovative and personalized treatments.

Landscape analysis of adjacent gene rearrangements reveals BCL2L14-ETV6 gene fusions in more aggressive triple-negative breast cancer

Triple-negative breast cancer (TNBC) accounts for 10 to 20% of breast cancer, with chemotherapy as its mainstay of treatment due to lack of well-defined targets, and recent genomic sequencing studies have revealed a paucity of TNBC-specific mutations. Recurrent gene fusions comprise a class of viable genetic targets in solid tumors; however, their role in breast cancer remains underappreciated due to the complexity of genomic rearrangements in this cancer. Our interrogation of the whole-genome sequencing data for 215 breast tumors catalogued 99 recurrent gene fusions, 57% of which are cryptic adjacent gene rearrangements (AGRs). The most frequent AGRs, BCL2L14-ETV6, TTC6-MIPOL1, ESR1-CCDC170, and AKAP8-BRD4, were preferentially found in the more aggressive forms of breast cancers that lack well-defined genetic targets. Among these, BCL2L14-ETV6 was exclusively detected in TNBC, and interrogation of four independent patient cohorts detected BCL2L14-ETV6 in 4.4 to 12.2% of TNBC tumors. Interestingly, these fusion-positive tumors exhibit more aggressive histopathological features, such as gross necrosis and high tumor grade. Amid TNBC subtypes, BCL2L14-ETV6 is most frequently detected in the mesenchymal entity, accounting for ∼19% of these tumors. Ectopic expression of BCL2L14-ETV6 fusions induce distinct expression changes from wild-type ETV6 and enhance cell motility and invasiveness of TNBC and benign breast epithelial cells. Furthermore, BCL2L14-ETV6 fusions prime partial epithelial-mesenchymal transition and endow resistance to paclitaxel treatment. Together, these data reveal AGRs as a class of underexplored genetic aberrations that could be pathological in breast cancer, and identify BCL2L14-ETV6 as a recurrent gene fusion in more aggressive form of TNBC tumors.

A population-based analysis of breast cancer incidence and survival by subtype in Ontario women

Background

Breast cancer (bca) is the type of cancer most frequently diagnosed among women in Canada. Breast cancer is categorized into various molecular subtypes by the expression of estrogen receptor (er), progesterone receptor (pgr), and her2 (human epidermal growth factor receptor 2). Currently, Canada has no national cancer registry with epidemiology data by subtype. Thus, we conducted a study to determine incidence, survival, and clinicopathologic characteristics by bca subtype [triple negative breast cancer (tnbc); her2+; and hormone receptor-positive (hr+), her2-] in Canadian women newly diagnosed with bca.

Methods

Female patients diagnosed between 1 April 2012 and 31 March 2016 (fiscal 2012-2015) were identified in the Ontario Cancer Registry, and individual patient data were linked to data in provincial health administrative databases. Descriptive statistics and Kaplan-Meier curves were generated.

Results

In this cohort, 3277 women (9.5%) had tnbc, 4902 (14.3%) had her2+ bca, and 22,247 (64.8%) had hr+, her2-breast cancer. The annual incidence was 15 per 100,000 for the tnbc group, 21-23 per 100,000 for the her2+ group, and 97-105 per 100,000 for the hr+, her2- group. The lowest median overall survival (mos) of 8.9 months was observed in women with clinical stage iv tnbc. In comparison, the mos was 37.3 months in those with her2+ disease and 35.2 months in those with and hr+, her2- metastatic bca.

Conclusions

In the present study, the most recent and largest administrative database analysis of a Canadian population to date, we observed a subtype distribution consistent with previously reported data, together with comparable annual incidence and overall survival patterns.

Prognostic value of tumor-infiltrating lymphocytes in patients with triple-negative breast cancer: a systematic review and meta-analysis

Background

The objective of this systematic review and meta-analysis was to determine the prognostic value of total tumor-infiltrating lymphocytes (TILs) and subtypes of TILs (CD4⁺, CD8⁺, and FOXP3⁺) in triple-negative breast cancer (TNBC).

Methods

A systematic search of the MEDLINE, EMBASE, and Web of Science databases was conducted to identified eligible articles published before August 2019. Study screening, data extraction, and risk of bias assessment were performed by two independent reviewers. Risk of bias on the study level was assessed using the ROBINS I tool and Quality in Prognosis Studies (QUIPS) tool. We performed a meta-analysis to obtain a pooled estimate of the prognostic role of TILs using Review Manager 5.3.

Results

In total, 37 studies were included in the final analysis. Compared to TNBC patients with low TIL levels, TNBC patients with high TIL levels showed a higher rate of pathological complete response (pCR) to treatment (odds ratio [OR] 2.14, 95% confidence interval [CI] 1.43–3.19). With each 10% increase in percentage of TILs, patients with TNBC had an increased pCR (OR 1.09, 95% CI 1.02–1.16). Compared to TNBC patients with low TIL levels, patients with high TIL levels had better overall survival (OS; hazard ratio [HR] 0.58, 95% CI 0.48–0.71) and disease-free survival (DFS; HR 0.66, 95% CI 0.57–0.76). Additionally, with a continuous increase in TIL levels, patients with TNBC had improved OS (HR 0.90, 95% CI 0.87–0.93) and DFS (HR 0.92, 95% CI 0.90–0.95). A high CD4⁺ TIL level was associated with better OS (HR 0.49, 95% CI 0.32–0.76) and DFS (HR 0.54, 95% CI 0.36–0.80). A high CD8⁺ TIL level was associated better DFS only (HR 0.55, 95% CI 0.38–0.81), as no statistical association was found with OS (HR 0.70, 95% CI 0.46–1.06). A high FOXP3⁺ TIL level also was associated with only DFS (HR 0.50, 95% CI 0.33–0.75) and not OS (HR 1.28, 95% CI 0.24–6.88).

Conclusions

TNBC with a high level of TILs showed better short-term and long-term prognoses. High levels of specific phenotypes of TILs (CD4⁺, CD8⁺, and FOXP3⁺) were predictive of a positive long-term prognosis for TNBC.

Histological subtypes in triple negative breast cancer are associated with specific information on survival

Much research has focused on finding novel prognostic biomarkers for triple negative breast cancer (TNBC), whereas only scattered information about the relation between histopathological features and survival in TNBC is available. This study aims to explore the prognostic value of histological subtypes in TNBC. A multicenter retrospective TNBC cohort was established from five Dutch hospitals. All non-neoadjuvantly treated, stage I-III patients with estrogen receptor, progesterone receptor and human epidermal growth factor receptor 2 negative breast cancer diagnosed between 2006 and 2014 were included. Clinical and follow-up data (overall survival; OS, relapse free survival; RFS) were retrieved and a central histopathological review was performed. Of 597 patients included (median follow up 62.8 months, median age at diagnosis 56.0 years), 19.4% developed a recurrence. The most prevalent histological subtypes were carcinoma of no special type (NST) (88.4%), metaplastic carcinoma (4.4%) and lobular carcinoma (3.4%). Collectively, tumors of special type were associated with a worse RFS and OS compared to carcinoma NST (RFS HR 1.89; 95% CI 1.18-3.03; p = 0.008; OS HR 1.94; 95% CI 1.28-2.92; p = 0.002). Substantial differences in survival, however, were present between the different histological subtypes. In the presented TNBC cohort, special histological subtype was in general associated with less favorable survival. However, within the group of tumors of special type there were differences in survival between the different subtypes. Accurate histological examination can provide specific prognostic information that may potentially enable more personalized treatment and surveillance regimes for TNBC patients.

CHARACTERISTICS AND PROGNOSIS OF TRIPLE-NEGATIVE BREAST CANCER PATIENTS: A CROATIAN SINGLE INstitution RETROSPECTIVE COHORT STUDY

Triple-negative breast cancer (TNBC) occurs in around one-sixth of all breast cancer (BC) patients, with the most aggressive behavior and worst prognosis of all BC subtypes. It is a heterogeneous disease, with specific molecular characteristics and natural dynamics of early recurrence and fast progression. Due to the lack of biomarkers or any valid treatment targets, it can only be treated with classic cytotoxic chemotherapy. We analyzed a cohort of 152 patients, median age 58 years, diagnosed with and treated for early stage TNBC at the University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia, during the 2009-2012 period. Patients were treated with primary surgical approach, adjuvant chemotherapy and adjuvant irradiation. We observed a relatively large proportion of locally advanced TNBC at diagnosis, with large tumor size and nodal involvement, with high grade and high proliferation index Ki67. Patient age, tumor size and lymph node involvement, as expected, were significant and clinically most important prognostic factors for 5-year disease-free survival (67%; 95% CI 60%-75%) and overall absolute survival rate (74%; 95% CI 66%-81%).

Three-dimensional radiomics of triple-negative breast cancer: Prediction of systemic recurrence

This paper evaluated 3-dimensional radiomics features of breast magnetic resonance imaging (MRI) as prognostic factors for predicting systemic recurrence in triple-negative breast cancer (TNBC) and validated the results with a different MRI scanner. The Rad score was generated from 3-dimensional radiomic features of MRI for 231 TNBCs (training set (GE scanner), n = 182; validation set (Philips scanner), n = 49). The Clinical and Rad models to predict systemic recurrence were built up and the models were externally validated. In the training set, the Rad score was significantly higher in the group with systemic recurrence (median, −8.430) than the group without (median, −9.873, P < 0.001). The C-index of the Rad model to predict systemic recurrence in the training set was 0.97, which was significantly higher than in the Clinical model (0.879; P = 0.009). When the models were externally validated, the C-index of the Rad model was 0.848, lower than the 0.939 of the Clinical model, although the difference was not statistically significant (P = 0.100). The Rad model for predicting systemic recurrence in TNBC showed a significantly higher C-index than the Clinical model. However, external validation with a different MRI scanner did not show the Rad model to be superior over the Clinical model.

Clinical features and their effect on outcomes of patients with triple negative breast cancer with or without lymph node involvement

Objective

Clinical and pathological characteristics of triple negative breast cancer (TNBC) treatment are required for escalation or de-escalation of treatment because of a lack of druggable targets. This study aimed to identify the factors affecting the risk of disease recurrence and disease-related death in patients with TNBC.

Methods

Patients with TNBC who were treated at the University Medical Centre Maribor between January 2010 and December 2017 were studied. Clinical and pathological data were analyzed using multivariate analysis and non-parametric tests. Subgroup analysis was performed to examine additional factors that affect 5-year overall survival (OS) and recurrence-free survival.

Results

Multivariate analysis showed that tumor size and the lymph node ratio (LNR) were significant risks in our population. Better discrimination of patients at risk of a shorter recurrence-free survival and OS was achieved by using the LNR. Only lymphovascular invasion was significant for predicting 5-year OS.

Conclusion

For risk-based decision-making systems, the LNR is useful for discriminating between high- and low-risk patients with TNBC.

Triple-negative breast cancer: Pretreatment magnetic resonance imaging features and clinicopathological factors associated with recurrence

PURPOSE

We aimed to investigate the magnetic resonance imaging (MRI) features and clinicopathologic factors with recurrence of triple-negative breast cancer (TNBC).

PATIENTS AND METHODS

We identified 281 patients with 288 surgically confirmed TNBC lesions who underwent pretreatment MRI between 2009 and 2015. The presence of intratumoral high signal on T2-weighted images, high-signal rim on diffusion-weighted images (DWI), and rim enhancement on the dynamic contrast-enhanced MRI and clinicopathological data were collected. Cox proportional analysis was performed.

RESULTS

Of the 288 lesions, 36 (12.5%) recurred after a median follow-up of 18 months (range, 3.6-68.3 months). Rim enhancement (hazard ratio [HR] = 3.15; 95% confidence interval [CI] = 1.01, 9.88; p = .048), and lymphovascular invasion (HR = 2.73, 95% CI = 1.20, 6.23; p = .016) were independently associated with disease recurrence. While fibroglandular volume, background parenchymal enhancement, intratumoral T2 high signal, and high-signal rim on DWI, were not found to be risk factors for recurrence.

CONCLUSION

Pretreatment MRI features may help predict a high risk of recurrence in patients with TNBC.

Comparison of Clinico-Pathological Presentations of Triple-Negative versus Triple-Positive and HER2 Iraqi Breast Cancer Patients

BACKGROUND

Breast cancer remains the most common malignancy among the Iraqi population. Affected patients exhibit different clinical behaviours according to the molecular subtypes of the tumour.

AIM

To identify the clinical and pathological presentations of the Iraqi breast cancer subtypes identified by Estrogen receptors (ER), Progesterone receptors (PR) and HER2 expressions.

PATIENTS AND METHODS

The present study comprised 486 Iraqi female patients diagnosed with breast cancer. ER, PR and HER2 contents of the primary tumours were assessed through immunohistochemical staining; classifying the patients into five different groups: Triple Negative (ER/PR negative/HER2 negative), Triple Positive (ER/PR positive/HER2 positive), Luminal A (ER/PR positive/HER2 negative), HER2 enriched ((ER/PR negative/HER2 positive) and all other subtypes.

RESULTS

The major registered subtype was the Luminal A which was encountered in 230 patients (47.3%), followed by the Triple Negative (14.6%), Triple Positive (13.6%) and HER2 Enriched (11.5%). Patients exhibiting the Triple Negative subtype were significantly younger than the rest of the groups and presented with larger size tumours. A significant difference in the distribution of the breast cancer stages was displayed (p < 0.05); the most advanced were noted among those with HER2 enriched tumours who exhibited the highest frequency of poorly differentiated carcinomas and lymph node involvement.

CONCLUSION

The most significant variations in the clinicopathological presentations were observed in the age and clinical stage of the patients at diagnosis. Adoption of breast cancer molecular subtype classification in countries with limited resources could serve as a valuable prognostic marker in the management of aggressive forms of the disease.

Sonography with vertical orientation feature predicts worse disease outcome in triple negative breast cancer

Objectives

Triple negative breast cancer (TNBC) is a heterogenous disease and associated with unfavorable outcomes. The role of sonographic features and its association with disease outcome in TNBC is uncertain. Our study aimed to determine the prognosis predictive value of sonographic features in TNBC.

Methods

Women with TNBC patients treated between January 2009 and December 2015 were retrospectively included. Patients’ clinic-pathological, sonographic features, recurrence-free survival (RFS), and breast cancer-specific survival (BCSS) events were reviewed and analyzed. Kaplan–Meier analysis and multivariable Cox regression were used to determine the prognostic factors in TNBC.

Results

A total of 433 TNBC patients were included. With a median follow-up of 4.8 years, 58 (13.4%) RFS and 35(8.1%) BCSS events were detected. Besides lymphatic vascular invasion (LVI), nuclear grade III, tumor >2.0 cm, and positive axillary lymph node (ALN), multivariable analysis found that vertical orientation in ultrasound imaging was independently associated with worse RFS (Hazard Ratio (HR) = 3.238; 95% Confidential Interval (CI), 1.661–6.312; P = 0.001) and BCSS (HR = 7.028; 95% CI, 3.199–15.436; P < 0.001). TNBC with vertical orientation in ultrasound imaging had higher ALN metastasis burden than those with sonographic parallel features (2.7 ± 1.0 vs 1.5 ± 0.2, P = 0.003).

Conclusions

TNBC presenting with vertical orientation in ultrasound imaging was associated with worse disease outcome and a greater number of ALN metastasis.

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In TNBC, vertical orientation in US was associated with inferior RFS.

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Vertical orientation in US independently predicted worse BCSS in TNBC.

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Vertical orientation in US was related with more ALN metastasis in TNBC patients.

Deep learning and manual assessment show that the absolute mitotic count does not contain prognostic information in triple negative breast cancer

PURPOSE

The prognostic value of mitotic count for invasive breast cancer is firmly established. As yet, however, limited studies have been aimed at assessing mitotic counts as a prognostic factor for triple negative breast cancers (TNBC). Here, we assessed the prognostic value of absolute mitotic counts for TNBC, using both deep learning and manual procedures.

METHODS

A retrospective TNBC cohort (n = 298) was used. The absolute manual mitotic count was assessed by averaging counts from three independent observers. Deep learning was performed using a convolutional neural network on digitized H&E slides. Multivariable Cox regression models for relapse-free survival and overall survival served as baseline models. These were expanded with dichotomized mitotic counts, attempting every possible cut-off value, and evaluated by means of the c-statistic.

RESULTS

We found that per 2 mm2 averaged manual mitotic counts ranged from 1 to 187 (mean 37.6, SD 23.4), whereas automatic counts ranged from 1 to 269 (mean 57.6; SD 42.2). None of the cut-off values improved the models' baseline c-statistic, for both manual and automatic assessments.

CONCLUSIONS

Based on our results we conclude that the level of proliferation, as reflected by mitotic count, does not serve as a prognostic factor for TNBC. Therefore, TNBC patient management based on mitotic count should be discouraged.

Differences in clinicopatholgic characteristics and risk of mortality between the triple positive and ER+/PR+/HER2- breast cancer subtypes

PURPOSE

This study compared the demographic and clinicopathologic characteristics and risk of mortality between the triple positive (TP) and ER+/PR+/HER2- breast cancer subtypes.

METHODS

Cases of first primary female invasive TP and ER+/PR+/HER2- breast cancer were obtained from the California Cancer Registry. Logistic regression analysis was used to compare differences in factors associated with the TP versus the ER+/PR+/HER2- subtype. Cox regression was used to compute the adjusted risk of breast cancer-specific mortality of the TP versus ER+/PR+/HER2-.

RESULTS

The odds of TP versus ER+/PR+/HER2- were higher with advanced stage, high grade, low SES, ≤ 45 years of age (OR 1.48; CI 1.40-1.55), black (OR 1.11; CI 1.02-1.21), Asian/Pacific Islander (OR 1.15; CI 1.09-1.22), and uninsured (OR 1.42; CI 1.15-1.73). Unadjusted survival analysis indicated worse survival for the TP when compared with the ER+/PR+/HER2- subtype. However, adjusted risk of mortality for the TP subtype was not statistically significantly worse than the ER+/PR+/HER2- subtype.

CONCLUSIONS

Young age, advanced stage and grade, low SES, black and API race, and lack of health insurance are more common in the TP subtype than in the ER+/PR+/HER2- subtype. However the risk of mortality between these two subtypes is similar.

A pilot study of low-dose CT perfusion imaging (LDCTPI) technology in patients with triple-negative breast cancer

PURPOSE

To investigate associations between the clinicopathologic features and CT perfusion parameters of triple-negative breast cancer (TNBC) and non-TNBC using low-dose computed tomography perfusion imaging (LDCTPI), and to find potential clinical applications in the prognosis assessment of TNBC.

MATERIALS AND METHODS

A total of 60 patients with breast cancer confirmed by pathological examination were studied prospectively using LDCTPI on a 64-slice spiral CT scanner. The acquired volume data were used for calculations, mapping, and analysis by using a tumor perfusion protocol in the CT perfusion software package to measure 2 parameters namely, blood flow (BF), and permeability surface (PS) area product. Patients were grouped into TNBC (n = 27) and non-TNBC (n = 33) subtypes. Associations between these two subtypes and clinicopathologic characteristics were evaluated by both univariate and multivariate logistic regression. CT perfusion parameters values were compared for clinicopathologic characteristics using independent 2-sample t test.

RESULTS

TNBC displayed higher CT perfusion parameters values (BF: 57.56±10.94 vs 52.70±7.79 mL/100 g/min, p = 0.006; PS: 38.98±9.46 vs 33.39±8.07 mL/100 g/min, p = 0.001) than non-TNBC. In addition, breast cancer with poorly histologic grade or positive Ki-67 expression showed higher BF and PS values than those with well and moderately histologic grade or negative Ki-67 expression (p < 0.05). TNBC had poorer histologic grade (P = 0.032) and higher Ki-67 expression (P = 0.013) than non-TNBC.

CONCLUSION

LDCTPI is a functional imaging technology from the perspective of hemodynamics with potential of clinical applications. The BF and PS values were higher in TNBC patient group than non-TNBC group. TNBC patients also have poorer clinicopathologic outcome.

Effects of adjuvant chemotherapy in T1N0M0 triple-negative breast cancer

OBJECTIVES

Patients with T1N0M0 breast cancers are considered to have an excellent prognosis, even in triple-negative breast cancer (TNBC), which is often associated with diminished recurrence-free survival (RFS) and overall survival. Chemotherapy remains the only adjuvant treatment for TNBC, but evidence that adjuvant chemotherapy is beneficial for stage T1N0M0 TNBC patients is limited. In this study, we aimed to evaluate the effect of adjuvant chemotherapy and the benefit of taxanes in T1N0M0 TNBC patients.

MATERIAL AND METHODS

A cohort of 354 consecutive patients with newly diagnosed T1N0M0 TNBC between January 2008 and December 2015 were included from the Fudan University Shanghai Cancer Center. Univariate and multivariate survival analyses were performed to compare patients treated with adjuvant chemotherapy with/without taxane addition.

RESULTS

Median follow-up was 45 months. Chemotherapy was used in 92.4% of patients. The 5-year estimated RFS rates of patients with and without adjuvant chemotherapy were 94.5% and 83.6%, respectively. In multivariate analysis, adjuvant chemotherapy and a lack of lymphovascular invasion were associated with a significant benefit for RFS. A significant RFS benefit from adjuvant chemotherapy was observed in T1c (hazard ratio, HR = 0.24, 95% CI [0.08-0.76], P = 0.014) but not in T1b (HR = 0.32, 95% CI [0.03-3.18], P = 0.330) subgroups. Addition of taxane to an anthracycline-based regimen was not significantly associated with improved RFS in T1N0M0 TNBC patients.

CONCLUSION

Adjuvant chemotherapy improves recurrence-free survival in T1c TNBC patients but not in T1b. Anthracycline-based taxane-free regimens might be sufficient to achieve RFS benefits in T1N0M0 TNBC patients.

Outcome for triple negative breast cancer in a retrospective cohort with an emphasis on response to platinum-based neoadjuvant therapy

Purpose

The rate of pathological complete response (pCR) for patients with triple negative breast cancer (TNBC) is increased when carboplatin is added to neo-adjuvant chemotherapy (NACT). However, while phase III trial data showing a survival benefit are awaited, carboplatin is not yet standard-of-care for TNBC. The aim of this study was to examine the rate of pCR and the outcome for those treated with carboplatin and to examine the predictors of response to therapy.

Methods

The retrospective series comprised 333 consecutive patients with TNBC (median follow-up time, 43 months). Adjuvant chemotherapy was given to 51% (n = 168) of patients and 29% (n = 97) received anthracycline–taxane NACT with carboplatin given to 9% (n = 31) of patients.

Results

Overall, 25% (n = 78) of patients experienced a breast cancer recurrence and 22% (n = 68) died from disease. A pCR breast and pCR breast/axilla was more common in those who received carboplatin (n = 18, 58% and n = 17, 55%, respectively) compared those who did not (n = 23, 36% and n = 18, 28%, respectively) (p = 0.041 and p = 0.011, respectively). By multivariable analysis, carboplatin and high tumor grade were independent predictors of pCR breast/axilla (OR_non-pCR = 0.17; 95% CI 0.06–0.54; p = 0.002; and OR_non-pCR = 0.05, 95% CI 0.01–0.27; p < 0.001, respectively). pCR breast/axilla was an independent predictor of DFS (HR_non-pCR=6.23; 95% CI 1.36–28.50; p = 0.018), metastasis-free survival (HR_non-pCR = 5.08; 95% CI 1.09–23.65; p = 0.038) and BCSS (HR_non-pCR = 8.52; 95% CI 1.09–66.64; p = 0.041).

Conclusion

Carboplatin therapy and high tumor grade are associated with a significant increase in the rate of pCR, which is an independent predictor of outcome. These data support the use of carboplatin in NACT for TNBC, while results from phase III studies are awaited.

Electronic supplementary material

The online version of this article (10.1007/s10549-018-5066-6) contains supplementary material, which is available to authorized users.

An accurate regression of developmental stages for breast cancer based on transcriptomic biomarkers

AIM

Breast cancers at different stages have tremendous differences on both phenotypic and molecular patterns. The developmental stage is an essential factor in the clinical decision of treatment plans, but was usually formulated as a classification problem, which ignored the consecutive relationships among them.

MATERIALS & METHODS

This study proposed a regression-based procedure to detect the stage biomarkers of breast cancers. Biomarkers were detected by the Lasso and Ridge algorithms.

RESULTS & CONCLUSION

A collaboration duet of Lasso and Ridge regression algorithms achieved the best performances, with classification accuracy (Acc) equal to 0.8294 and regression goodness-of-fit (R²) equal to 0.7810. The 265 biomarker genes were enriched with the signal peptide-based secretion function with the Bonferroni-corrected p-value equal to 6.9408e-3 and false discovery rate (FDR) equal to 1.1614e-2.