Predictive markers of endocrine response in breast cancer

Gene expression associated with endocrine therapy resistance in estrogen receptor-positive breast cancer

Despite endocrine therapy (ET), approximately 20-40% of Stage I-III estrogen receptor-positive breast cancer (ER + BC) patients experience recurrence. Recurrence while on ET is indicative of ET resistance. This study aimed to identify differentially expressed genes (DEGs) associated with recurrence during ET (ET resistance) and to explore gene expression differences across PAM50 molecular subtypes. Eighty tumor specimens from 79 patients treated at the City of Hope Comprehensive Cancer Center (2012-2016) were analyzed using NanoString technology. Fourteen patients (17.7%) experienced recurrence over a median follow-up of 68 months (range 35-104 months). Key upregulated DEGs in the recurrence group included EZH2 (log2 fold change[log2FC]: 0.67, p = 0.0017), WNT11 (log2FC: 1.08, p = 0.0088), ITGB6 (log2FC: 0.80, p = 0.0312), and TOP2A (log2FC: 0.79, p = 0.0381). Downregulated DEGs included SNAI2 (log2FC: - 0.63, p = 0.0055), ITPR1 (log2FC: - 0.75, p = 0.0083), CD10 (log2FC: - 0.70, p = 0.0092), PTEN (log2FC: - 0.29, p = 0.0163), VRD (log2FC: - 0.46, p = 0.0184), and WNT5A (log2FC: - 0.76, p = 0.0272). EZH2 and TOP2A were positively correlated with proliferation scores, while WNT11 and ITGB6 emerged as potential biomarkers independently associated with recurrence. These findings suggest novel biomarker candidates that could help overcome ET resistance, reduce recurrence, and improve outcomes in ER + BC.

Breast cancer histopathology, classification and clinical management: Current perspectives

Breast cancer (BC) manifests as a diverse group of malignancies and presents as a wide array of tumors with distinct morphological, biological and clinical characteristics. Molecular classification of BC serves as the basis for current precision-oriented therapeutic strategies. Upcoming therapeutic strategies will emphasize personalized medicine and tailoring treatments according to each patient's specific needs. These approaches will involve modulating the therapy intensity based on the biological characteristics of tumours and early predictive indicators, allowing for more precise and adaptable care in oncology. Additionally, there remains an unfulfilled requirement for the creation of new medications to treat breast cancer in its early stages, as well as in advanced cases. This review article presents an extensive examination of breast cancer, delving into its prevalence, contributing factors, molecular and cellular features and therapeutic interventions.

BCAR4 Expression as a Predictive Biomarker for Endocrine Therapy Resistance in Breast Cancer

BACKGROUND

Breast cancer, particularly the estrogen receptor positive (ER+) subtype, remains a leading cause of cancer-related death among women. Endocrine therapy is the most effective treatment for ER+ breast cancer; however, the development of resistance presents a significant challenge. This study explored the role of the breast cancer antiestrogen resistance 4 (BCAR4) gene as a potential driver of resistance and a pivotal biomarker in breast cancer.

PATIENTS AND METHODS

The researchers undertook a comprehensive analysis of 1743 patients spanning 6 independent cohorts. They examined the association of BCAR4 expression with patient outcomes across all breast cancer types and the PAM50 molecular subtypes. The relationship between elevated BCAR4 expression and resistance to endocrine therapy including AIs, the prevailing standard-of-care for endocrine therapy, was also investigated.

RESULTS

This meta-analysis corroborated the link between BCAR4 expression and adverse outcomes as well as resistance to endocrine therapy in breast cancer. Notably, BCAR4 expression is clinically significant in luminal A and B subtypes. Additionally, an association between BCAR4 expression and resistance to AI treatment was discerned.

CONCLUSION

This study expands on previous findings by demonstrating that BCAR4 expression is associated with resistance to newer therapies. The identification of patients with intrinsic resistance to hormone therapy is crucial to avoid ineffective treatment strategies. These findings contribute to our understanding of endocrine therapy resistance in breast cancer and could potentially guide the development of more effective treatment strategies.

Influence of tumor microenvironment on the different breast cancer subtypes and applied therapies

Despite the significant improvements made in breast cancer therapy during the last decades, this disease still has increasing incidence and mortality rates. Different targets involved in general processes, like cell proliferation and survival, have become alternative therapeutic options for this disease, with some of them already used in clinic, like the CDK4/6 inhibitors for luminal A tumors treatment. Nevertheless, there is a demand for novel therapeutic strategies focused not only on tumor cells, but also on their microenvironment. Tumor microenvironment (TME) is a very complex and dynamic system that, more than surrounding and supporting tumor cells, actively participates in tumor development and progression. During the last decades, it has become clear that the cellular and acellular components of TME differ between the various breast cancer subtypes and shape the differences regarding their severity and prognosis. The pivotal role of the TME in controlling tumor growth and influencing responses to therapy represents a potential source for novel targets and therapeutic strategies. In this review, we present a description of the multiple therapeutic options used for different breast cancer subtypes, as well as the influence that the TME may exert on the development of the disease and on the response to the distinct therapies, which in some cases may explain their failure by the occurrence of relapses and resistance. Furthermore, the ongoing studies focused on the use of TME components for developing potential cancer treatments are described.

Prediction of Late Recurrence and Distant Metastasis in Early-stage Breast Cancer: Overview of Current and Emerging Biomarkers

Recently, a significant number of breast cancer (BC) patients have been diagnosed at an early stage. It is therefore critical to accurately predict the risk of recurrence and distant metastasis for better management of BC in this setting. Clinicopathologic patterns, particularly lymph node status, tumor size, and hormonal receptor status are routinely used to identify women at increased risk of recurrence. However, these factors have limitations regarding their predictive ability for late metastasis risk in patients with early BC. Emerging molecular signatures using gene expression-based approaches have improved the prognostic and predictive accuracy for this indication. However, the use of their based-scores for risk assessment has provided contradictory findings. Therefore, developing and using newly emerged alternative predictive and prognostic biomarkers for identifying patients at high- and low-risk is of great importance. The present review discusses some serum biomarkers and multigene profiling scores for predicting late recurrence and distant metastasis in early-stage BC based on recently published studies and clinical trials.

Clinical value of CTLA4 combined with clinicopathological factors in evaluating the prognosis of breast cancer

Background

Clinical prediction of breast cancer prognosis relies on both clinical-pathological features and biological markers. Many studies have revealed that tumor cytotoxic T lymphocyte antigen 4 (CTLA4) expression may present prognostic predicting value in cancers. We intended to explore the prognostic value of significant clinicopathological parameters and CTLA4 for predicting survival of patients with breast cancer.

Methods

A total of 229 breast cancer patients who had radical surgery treatment between Sep 2009 and April 2011 were enrolled in this study. Immunohistochemical staining was performed to evaluate CTLA4 grade and Ki-67 index in breast cancer tissue. Univariate and multivariate logistic analysis, Kaplan-Meier survival analysis and ROC curve were used to explore the association between CTLA4 or clinicopathological parameters and disease-free survival (DFS). A nomogram was constructed based on the regression model to predict DFS of patients with breast cancer.

Results

CTLA4 grade (OR 1.730, 95% CI: 1.213-2.468, P=0.002), Ki-67 (OR 1.449, 95% CI: 1.069-1.964, P=0.017) and N stage (lymph node metastasis) (OR 2.268, 95% CI: 1.588-3.303, P=0.000) showed significantly association with DFS of breast cancer patients. All these factors were independent predictors for poor survival, as patients with stage N2-3 tumors, high CTLA4 grade and Ki-67 index showed low survival probability (P<0.01). The conjunction of these factors exhibited good discrimination value (AUC 0.815, 95% CI: 0.749-0.882, P=0.000). Nomogram performed based on CTLA4 grade, Ki-67 index and N stage provided an efficient method to predict DFS of patients with breast cancer.

Conclusions

The high expression of CTLA4 and Ki-67 together with lymph node metastasis in breast cancer are independent risk factors that affect the prognosis of breast cancer patients. They have the potentiality to be utilized conjunctively as predictor in clinical practice.

Patterns of biomarker expression in patients treated with primary endocrine therapy - a unique insight using core needle biopsy tissue microarray

Purpose

Prediction of response to primary endocrine therapy (PET) in older women is based on measurement of oestrogen receptor (ER), progesterone receptor (PgR) and human epidermal growth factor (HER)-2. This study uses a unique method for construction of core needle biopsy (CNB) tissue microarray (TMA), to correlate expression of a panel of 17 biomarkers with clinical outcome, in patients receiving PET.

Methods

Over 37 years (1973–2010), 1758 older (≥ 70 years) women with operable primary breast cancer were managed in a single institution. Of these, 693 had sufficient good-quality CNB to construct TMA, of which 334 had ER-positive tumours treated by PET with a minimum of 6-month follow-up. A panel of biomarkers was measured by immunohistochemistry (ER, PgR, HER2, Ki-67, p53, CK5/6, CK 7/8, EGFR, BCL-2, MUC1, VEGF, LKB1, BRCA1, HER3, HER4, PTEN and AIB1). Expression of each biomarker was dichotomised into ‘low’ or ‘high’ based on breast cancer-specific survival (BCSS).

Results

From the panel of biomarkers, multivariate analysis showed:

High ER (p = 0.003) and PgR (p = 0.002) were associated with clinical benefit of PET at 6 months, as opposed to progressive disease.

High ER (p = 0.0023), PgR (p < 0.001) and BCL-2 (p = 0.043) and low LKB1 (p = 0.022) were associated with longer time to progression.

High PgR (p < 0.001) and low MUC1 (p = 0.021) were associated with better BCSS.

Expression of other biomarkers did not show any significant correlation.

Conclusions

In addition to ER and PgR; MUC1, BCL-2 and LKB1 are important in determining the outcome of PET in this cohort.

Electronic supplementary material

The online version of this article (10.1007/s10549-020-06023-4) contains supplementary material, which is available to authorised users.

Breast cancer, screening and diagnostic tools: All you need to know

Breast cancer is one of the most frequent malignancies among women worldwide. Methods for screening and diagnosis allow health care professionals to provide personalized treatments that improve the outcome and survival. Scientists and physicians are working side-by-side to develop evidence-based guidelines and equipment to detect cancer earlier. However, the lack of comprehensive interdisciplinary information and understanding between biomedical, medical, and technology professionals makes innovation of new screening and diagnosis tools difficult. This critical review gathers, for the first time, information concerning normal breast and cancer biology, established and emerging methods for screening and diagnosis, staging and grading, molecular and genetic biomarkers. Our purpose is to address key interdisciplinary information about these methods for physicians and scientists. Only the multidisciplinary interaction and communication between scientists, health care professionals, technical experts and patients will lead to the development of better detection tools and methods for an improved screening and early diagnosis.

Continuous Exposure of Breast Cancer Cells to Tamoxifen Upregulates GPER-1 and Increases Cell Proliferation

GPER-1 is a novel membrane sited G protein-coupled estrogen receptor. Clinical studies have shown that patients suffering an estrogen receptor α (ERα)/GPER-1 positive, breast cancer have a lower survival rate than those who have developed ERα-positive/GPER-1 negative tumors. Moreover, absence of GPER-1 improves the prognosis of patients treated with tamoxifen, the most used selective estrogen receptor modulator to treat ERα-positive breast cancer. MCF-7 breast cancer cells were continuously treated with 1,000 nM tamoxifen for 7 days to investigate its effect on GPER-1 protein expression, cell proliferation and intracellular [Ca2+]i mobilization, a key signaling pathway. Breast cancer cells continuously treated with tamoxifen, exhibited a robust [Ca2+]i mobilization after stimulation with 1,000 nM tamoxifen, a response that was blunted by preincubation of cells with G15, a commercial GPER-1 antagonist. Continuously treated cells also displayed a high [Ca2+]i mobilization in response to a commercial GPER-1 agonist (G1) and to estrogen, in a magnitude that doubled the response observed in untreated cells and was almost completely abolished by G15. Proliferation of cells continuously treated with tamoxifen and stimulated with 2,000 nM tamoxifen, was also higher than that observed in untreated cells in a degree that was approximately 90% attributable to GPER-1. Finally, prolonged tamoxifen treatment did not increase ERα expression, but did overexpress the kinin B1 receptor, another GPCR, which we have previously shown is highly expressed in breast tumors and increases proliferation of breast cancer cells. Although we cannot fully extrapolate the results obtained in vitro to the patients, our results shed some light on the occurrence of drug resistance in breast cancer patients who are ERα/GPER-1 positive, have been treated with tamoxifen and display low survival rate. Overexpression of kinin B1 receptor may explain the increased proliferative response observed in breast tumors under continuous treatment with tamoxifen.

Treatment effect of palbociclib plus endocrine therapy by prognostic and intrinsic subtype and biomarker analysis in patients with bone-only disease: a joint analysis of PALOMA-2 and PALOMA-3 clinical trials

Purpose

This analysis evaluated the relationship between treatment-free interval (TFI, in PALOMA-2)/disease-free interval (DFI, in PALOMA-3) and progression-free survival (PFS) and overall survival (OS, in PALOMA-3), treatment effect in patients with bone-only disease, and whether intrinsic subtype affects PFS in patients receiving palbociclib.

Methods

Data were from phase 3, randomized PALOMA-2 and PALOMA-3 clinical studies of hormone receptor‒positive/human epidermal growth factor receptor 2‒negative (HR+ /HER2−) advanced breast cancer (ABC) patients receiving endocrine therapy plus palbociclib or placebo. Subpopulation treatment effect pattern plot (STEPP) analysis evaluated the association between DFI and PFS and OS. PFS by luminal subtype and cyclin-dependent kinase (CDK) 4/6 or endocrine pathway gene expression levels were evaluated in patients with bone-only disease; median PFS and OS were estimated by the Kaplan–Meier method.

Results

Median durations of TFI were 37.1 and 30.9 months (PALOMA-2) and DFI were 49.2 and 52.0 months (PALOMA-3) in the palbociclib and placebo groups, respectively. Among the PALOMA-2 biomarker population (n = 454), 23% had bone-only disease; median PFS was longer with palbociclib versus placebo (31.3 vs 11.2 months; hazard ratio, 0.41; 95% CI 0.25‒0.69). The interaction effect of bone-only versus visceral disease subgroups on median PFS with palbociclib was not significant (P = 0.262). Among the PALOMA-3 biomarker population (n = 302), 27% had bone-only disease. STEPP analyses showed that palbociclib PFS benefit was not affected by DFI, and that palbociclib OS effect may be smaller in patients with short DFIs. Among patients who provided metastatic tumor tissues (n = 142), regardless of luminal A (hazard ratio, 0.23; 95% CI 0.11‒0.47; P = 0.0000158) or luminal B (hazard ratio, 0.26; 95% CI 0.12‒0.56; P = 0.000269) subtype, palbociclib improved PFS versus placebo.

Conclusions

These findings support palbociclib plus endocrine therapy as standard of care for HR+ /HER2− ABC patients, regardless of baseline TFI/DFI or intrinsic molecular subtype, including patients with bone-only disease.

Trial registration

Pfizer (clinicaltrials.gov:NCT01740427, NCT01942135).

Androgen receptor expression inversely correlates with histological grade and N stage in ER+/PgRlow male breast cancer

PURPOSE

Androgen Receptor (AR) positivity is often displayed in breast cancer and especially in Male Breast Cancer (MBC), where it appears to be a heterogeneous feature, with its expression ranging between 38 and 81% of cases. Given the fact that circulating androgens represent the most important sex hormones in males and that breast carcinogenesis is characteristically subjected to hormonal mechanisms, our purpose was to investigate the clinicopathological significance of AR in MBC assessing if its expression could be associated with parameters of tumor aggressiveness.

METHODS

Clinical and pathological data were retrospectively reviewed for male patients with a diagnosis of invasive breast cancer. AR status was detected by immunohistochemistry on formalin-fixed, paraffin-embedded tumoral tissue sections. Correlations between AR expression and histopathological features were assessed using univariate and multiple comparisons where appropriate, assuming P values < 0.05 as statistically significant.

RESULTS

The study included 44 consecutive male patients. AR expression ranged between 10 and 98% and the majority of cases presented a moderate to high expression of this receptor. Adopting a 20% PgR cut-off, statistical analyses highlighted a different behavior of AR: in ER⁺/PgR^high group, it positively correlated with the other steroid receptors pointing out the importance of hormonal cross-talk: in ER⁺/PgR^low group, AR status inversely correlated with histological grade and lymph node status.

CONCLUSION

Hormonal factors reveal to play a crucial role in MBC carcinogenesis and progression. Intriguingly, in ER⁺/PgR^low tumors AR expression significantly correlates with lymph node status, hinting at a favorable biological role of AR in this tumor subgroup.

Is mammographic density a marker of breast cancer phenotypes?

PURPOSE

To investigate the association between mammographic density (MD) phenotypes and both clinicopathologic features of breast cancer (BC) and tumor location.

METHODS

MD was measured for 297 BC-affected females using qualitative (visual method) and quantitative (fully automated area-based method) approaches. Radiologists' description, visible external markers, and surgical scar were used to establish the location of tumors. Binary logistic regression models were used to assess the association between MD phenotypes and BC clinicopathologic features.

RESULTS

Categorical and numerical MD measures showed no association with clinicopathologic features of BC (p > 0.05). Participants with higher BI-RADS scores [(51-75% glandular) and (> 75% glandular)] (p < 0.001), and percent density (PD) categories [PD (21-49%) and PD ≥ 50%] (p = 0.01) were more likely to have tumors emanating from dense areas. Additionally, tumors were commonly found in dense regions of the breast among patients with higher medians of PD (p = 0.001), dense area (DA) (p = 0.02), and lower medians of non-dense area (NDA) (p < 0.001). Adjusted logistic regression models showed that high BI-RADS density (> 75% glandular) has an almost fivefold increased odds of tumors developing within dense areas (OR 4.99, 95% CI 0.93-25.9; p = 0.05. PD (OR 1.02, 95% CI 1-1.03, p = 0.002) and NDA (OR 0.99, 95% CI 0.991-0.997, p < 0.001) had very small effect on tumor location. Compared to tumors within non-dense areas, tumors in dense areas tended to exhibit human epidermal growth factor receptor 2 positive (p = 0.05) and carcinoma in situ (p = 0.01) characteristics.

CONCLUSION

MD shows no significant association with clinicopathologic features of BC. However, BC was more likely to originate from dense tissue, with tumors in dense regions having human epidermal growth receptor 2 positive and carcinoma in situ characteristics.

Cannabinoids and Hormone Receptor-Positive Breast Cancer Treatment

Breast cancer (BC) is the most common cancer in women worldwide. Approximately 70–80% of BCs express estrogen receptors (ER), which predict the response to endocrine therapy (ET), and are therefore hormone receptor-positive (HR+). Endogenous cannabinoids together with cannabinoid receptor 1 and 2 (CB1, CB2) constitute the basis of the endocannabinoid system. Interactions of cannabinoids with hypothalamic–pituitary–gonadal axis hormones are well documented, and two studies found a positive correlation between peak plasma endogenous cannabinoid anandamide with peak plasma 17β-estradiol, luteinizing hormone and follicle-stimulating hormone levels at ovulation in healthy premenopausal women. Do cannabinoids have an effect on HR+ BC? In this paper we review known and possible interactions between cannabinoids and specific HR+ BC treatments. In preclinical studies, CB1 and CB2 agonists (i.e., anandamide, THC) have been shown to inhibit the proliferation of ER positive BC cell lines. There is less evidence for antitumor cannabinoid action in HR+ BC in animal models and there are no clinical trials exploring the effects of cannabinoids on HR+ BC treatment outcomes. Two studies have shown that tamoxifen and several other selective estrogen receptor modulators (SERM) can act as inverse agonists on CB1 and CB2, an interaction with possible clinical consequences. In addition, cannabinoid action could interact with other commonly used endocrine and targeted therapies used in the treatment of HR+ BC.

INSIGHTS ON AROMATASE IMMUNOHISTOCHEMISTRY: VARIATIONS BETWEEN INTRINSIC MOLECULAR SUBTYPES OF BREAST CANCERS

CONTEXT

Aromatase is a key enzyme in local estrogen production by androgen conversion, especially in women post-menopause. There have been controversies concerning aromatase localization in breast carcinomas and its association with current histopathological variables.

MATERIAL AND METHODS

Using polyclonal antibody immunohistochemistry we assessed (by intensity and percentage scores) the immunolocalization of aromatase in 70 tissue samples, and described particularities within the molecular subtypes of breast cancer.

RESULTS

Aromatase was found in all tissue compartments: tumor (95.7%), stroma (58.6%) and adipose tissue (94.3%). Aromatase expression in tumor cells correlated inversely with tumor grading (p=-0.361, p=0.027), and positively with estrogen receptor status (ER, p=0.143, p<0.001). Dividing the study group by intrinsic subtypes, a strongly inversely association between tumor aromatase and grading (p=-0.486, p<0.001), and between stromal aromatase and Ki67-index (p=-0.448, p=0.048) was observed in luminal A breast cancer. Tumor aromatase and ER percentage scores had stronger correlations in luminal B HER2 negative (p=0.632, p=0.002), and positive (p=0.324, p=0.026) tumors. In contrast, in triple negative tumors, a positive association stromal aromatase and Ki67 index (p=-0.359, p=0.007) was observed.

CONCLUSION

Local aromatase was linked to better tumor differentiation and proliferation in luminal breast subtypes, and not in triple negative cases, suggesting a potential prognostic role of aromatase in breast carcinomas.

CTCs Expression Profiling for Advanced Breast Cancer Monitoring

The study of circulating tumor cells (CTCs) has a huge clinical interest in advance and metastatic breast cancer patients. However, many approaches are biased by the use of epithelial markers, which underestimate non-epithelial CTCs phenotypes. CTCs enumeration provides valuable prognostic information; however, molecular characterization could be the best option to monitor patients throughout the disease since it may provide more relevant clinical information to the physicians. In this work, we aimed at enumerating and performing a molecular characterization of CTCs from a cohort of 20 patients with metastatic breast cancer (MBC), monitoring the disease at different time points of the therapy, and at progression when it occurred. To this end, we used a CTC negative enrichment protocol that allowed us to recover a higher variety of CTCs phenotypes. With this strategy, we were able to obtain gene expression data from CTCs from all the patients. In addition, we found that high expression levels of PALB2 and MYC were associated with a worse outcome. Interestingly, we identified that CTCs with an EpCAM^highVIM^lowALDH1A1^high signature showed both shorter overall survival (OS) and progression-free survival (PFS), suggesting that CTCs with epithelial-stem features had the most aggressive phenotype.

Silencing growth hormone receptor inhibits estrogen receptor negative breast cancer through ATP-binding cassette sub-family G member 2

Growth hormone receptor (GHR) plays a vital role in breast cancer chemoresistance and metastasis but the mechanism is not fully understood. We determined if GHR could be a potential therapeutic target for estrogen receptor negative (ER-ve) breast cancer, which are highly chemoresistant and metastatic. GHR was stably knocked down in ER-ve breast cancer cells and its effect on cell proliferation, metastatic behavior, and chemosensitivity to docetaxel (DT) was assessed. Microarray analysis was performed to identify potential GHR downstream targets involved in chemoresistance. GHR and ATP-binding cassette sub-family G member 2 (ABCG2) overexpression and knockdown studies were performed to investigate the mechanism of GHR-induced chemoresistance. Patient-derived xenografts was used to study the effect of GHR and ABCG2. Immunohistochemical data was used to determine the correlation between GHR, pAKT, pmTOR, and ABCG2 expressions. GHR silencing drastically reduced the chemoresistant and metastatic behavior of ER-ve breast cancer cells and also inhibited AKT/mTOR pathway. In contrast, activation, or overexpression of GHR increased chemoresistance and metastasis by increasing the expression and promoter activity, of ABCG2. Inhibition of JAK2/STAT5 signaling repressed GHR-induced ABCG2 promoter activity and expression. Further, ABCG2 knockdown significantly increased the chemosensitivity. Finally, patient-derived xenograft studies revealed the role of GHR in chemoresistance. Overall, these findings demonstrate that targeting GHR could be a novel therapeutic approach to overcome chemoresistance and associated metastasis in aggressive ER-ve breast cancers.