Cancer Chemotherapy and Pharmacology

, Volume 69, Issue 2, pp 533–546 | Cite as

Triple-negative phenotype is of adverse prognostic value in patients treated with dose-dense sequential adjuvant chemotherapy: a translational research analysis in the context of a Hellenic Cooperative Oncology Group (HeCOG) randomized phase III trial

  • P. Skarlos
  • C. Christodoulou
  • K. T. Kalogeras
  • A. G. Eleftheraki
  • M. Bobos
  • A. Batistatou
  • C. Valavanis
  • O. Tzaida
  • E. Timotheadou
  • R. Kronenwett
  • R. M. Wirtz
  • I. Kostopoulos
  • D. Televantou
  • E. Koutselini
  • I. Papaspirou
  • C. A. Papadimitriou
  • D. Pectasides
  • H. Gogas
  • G. Aravantinos
  • N. Pavlidis
  • P. Arapantoni
  • D. V. Skarlos
  • G. Fountzilas
Original Article

Abstract

Purpose

It is well recognized that breast cancer is a heterogeneous disease. The purpose of the current study was to classify patients according to the immunohistochemical phenotype of their tumors in an effort to evaluate the outcome of the respective groups of patients and specifically of those with triple-negative breast cancer (TNBC) following dose-dense sequential adjuvant chemotherapy.

Methods

A total of 595 patients with high-risk breast cancer were treated with adjuvant anthracycline-based dose-dense sequential chemotherapy with or without paclitaxel in the context of a randomized study. ER, PgR, HER2, Ki67, EGFR, and CK5 protein expression were evaluated in 298 formalin-fixed paraffin-embedded tumor samples by immunohistochemistry (IHC). HER2 was also evaluated by chromogen in situ hybridization (CISH). HER2 status and Ki67 protein expression differentiated luminal IHC subtypes (luminal B tumors being HER2 and/or Ki67-positive).

Results

Among the 298 tumors, the immunohistochemical panel classified 37 (12%) as luminal A, 198 (66%) as luminal B, 27 (9%) as HER2 enriched, and 36 (12%) as TNBC. The median follow-up time was 97 months. Patients with luminal A tumors had the best prognosis, with improved disease-free survival (log-rank, P = 0.033) and overall survival (P = 0.006) compared with the other three tumor subtypes. The three subtypes had an increased risk for relapse and death compared with luminal A in multivariate analysis, as well. No benefit from paclitaxel treatment was detected in any of the four subtypes or the total cohort. Hierarchical clustering based on mRNA expression of ER, PgR, and HER2 by quantitative RT-PCR identified patient groups that were comparable to the subtypes identified by IHC.

Conclusions

The results of this study confirm that triple negative, luminal B and HER2-enriched phenotypes identified by IHC are of adverse prognostic value in high-risk breast cancer patients treated with dose-dense sequential adjuvant chemotherapy.

Keywords

Immunophenotypic subtypes mRNA subtypes mRNA expression Triple-negative breast cancer HER2 enriched subtype Prognostic value 

Notes

Acknowledgments

The authors are deeply indebted to all patients who participated in the study and provided biological material for translational research. The authors also wish to thank Evita Fragou and Dimitra Katsala for monitoring the study, Maria Moschoni for coordinating the data management, and Thalia Spinari for tissue sample collection and Ioanna Panou for secretarial assistance. On behalf of the Hellenic Foundation for Cancer Research, Athens, Greece, the senior investigator author (GF) has pending patent applications with Siemens Healthcare Diagnostics, Tarrytown, NY, USA. Translational research was supported by a HeCOG research grant: HE TRANS_BR. The senior investigator (GF) has received Commercial Research Funding by Roche Hellas SA and Genesis Pharma SA, Athens, Greece.

Supplementary material

280_2011_1730_MOESM1_ESM.docx (106 kb)
Supplementary material 1 (DOC 107 kb)

References

  1. 1.
    Bohmann K, Hennig G, Rogel U, Poremba C, Mueller BM, Fritz P, Stoerkel S, Schaefer KL (2009) RNA extraction from archival formalin-fixed paraffin-embedded tissue: a comparison of manual, semiautomated, and fully automated purification methods. Clin Chem 55:1719–1727PubMedCrossRefGoogle Scholar
  2. 2.
    Bonadonna G, Brusamolino E, Valagussa P, Rossi A, Brugnatelli L, Brambilla C, De Lena M, Tancini G, Bajetta E, Musumeci R, Veronesi U (1976) Combination chemotherapy as an adjuvant treatment in operable breast cancer. N Engl J Med 294:405–410PubMedCrossRefGoogle Scholar
  3. 3.
    Carey LA, Dees EC, Sawyer L, Gatti L, Moore DT, Collichio F, Ollila DW, Sartor CI, Graham ML, Perou CM (2007) The triple negative paradox: primary tumor chemosensitivity of breast cancer subtypes. Clin Cancer Res 13:2329–2334PubMedCrossRefGoogle Scholar
  4. 4.
    Cheang MC, Chia SK, Voduc D, Gao D, Leung S, Snider J, Watson M, Davies S, Bernard PS, Parker JS, Perou CM, Ellis MJ, Nielsen TO (2009) Ki67 index, HER2 status, and prognosis of patients with luminal B breast cancer. J Natl Cancer Inst 101:736–750PubMedCrossRefGoogle Scholar
  5. 5.
    Cheang MC, Voduc D, Bajdik C, Leung S, McKinney S, Chia SK, Perou CM, Nielsen TO (2008) Basal-like breast cancer defined by five biomarkers has superior prognostic value than triple-negative phenotype. Clin Cancer Res 14:1368–1376PubMedCrossRefGoogle Scholar
  6. 6.
    Christodoulou C, Kostopoulos I, Kalofonos HP, Lianos E, Bobos M, Briasoulis E, Gogas H, Razis E, Skarlos DV, Fountzilas G (2009) Trastuzumab combined with pegylated liposomal doxorubicin in patients with metastatic breast cancer. Phase II Study of the Hellenic Cooperative Oncology Group (HeCOG) with biomarker evaluation. Oncology 76:275–285PubMedCrossRefGoogle Scholar
  7. 7.
    Citron ML, Berry DA, Cirrincione C, Hudis C, Winer EP, Gradishar WJ, Davidson NE, Martino S, Livingston R, Ingle JN, Perez EA, Carpenter J, Hurd D, Holland JF, Smith BL, Sartor CI, Leung EH, Abrams J, Schilsky RL, Muss HB, Norton L (2003) Randomized trial of dose-dense versus conventionally scheduled and sequential versus concurrent combination chemotherapy as postoperative adjuvant treatment of node-positive primary breast cancer: first report of Intergroup Trial C9741/Cancer and Leukemia Group B Trial 9741. J Clin Oncol Official J Am Soc Clin Oncol 21:1431–1439CrossRefGoogle Scholar
  8. 8.
    Colleoni M, Cole BF, Viale G, Regan MM, Price KN, Maiorano E, Mastropasqua MG, Crivellari D, Gelber RD, Goldhirsch A, Coates AS, Gusterson BA (2010) Classical cyclophosphamide, methotrexate, and fluorouracil chemotherapy is more effective in triple-negative, node-negative breast cancer: results from two randomized trials of adjuvant chemoendocrine therapy for node-negative breast cancer. J Clin Oncol Official J Am Soc Clin Oncol 28:2966–2973CrossRefGoogle Scholar
  9. 9.
    Di Cosimo S, Baselga J (2010) Management of breast cancer with targeted agents: importance of heterogeneity (corrected). Nat Rev Clin Oncol 7:139–147PubMedCrossRefGoogle Scholar
  10. 10.
    Diallo-Danebrock R, Ting E, Gluz O, Herr A, Mohrmann S, Geddert H, Rody A, Schaefer KL, Baldus SE, Hartmann A, Wild PJ, Burson M, Gabbert HE, Nitz U, Poremba C (2007) Protein expression profiling in high-risk breast cancer patients treated with high-dose or conventional dose-dense chemotherapy. Clin Cancer Res 13:488–497PubMedCrossRefGoogle Scholar
  11. 11.
    Dowsett M, Cuzick J, Wale C, Forbes J, Mallon EA, Salter J, Quinn E, Dunbier A, Baum M, Buzdar A, Howell A, Bugarini R, Baehner FL, Shak S (2010) Prediction of risk of distant recurrence using the 21-gene recurrence score in node-negative and node-positive postmenopausal patients with breast cancer treated with anastrozole or tamoxifen: a TransATAC study. J Clin Oncol Official J Am Soc Clin Oncol 28:1829–1834CrossRefGoogle Scholar
  12. 12.
    Early Breast Cancer Trialists’ Colaborative Group (EBCTCG) (2005) Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 365:1687–1717Google Scholar
  13. 13.
    Falo C, Moreno A, Varela M, Lloveras B, Figueras A, Escobedo A (2007) HER-2/neu status and response to CMF: retrospective study in a series of operable breast cancer treated with primary CMF chemotherapy. J Cancer Res Clin Oncol 133:423–429PubMedCrossRefGoogle Scholar
  14. 14.
    Fountzilas G, Skarlos D, Dafni U, Gogas H, Briasoulis E, Pectasides D, Papadimitriou C, Markopoulos C, Polychronis A, Kalofonos HP, Siafaka V, Kosmidis P, Timotheadou E, Tsavdaridis D, Bafaloukos D, Papakostas P, Razis E, Makrantonakis P, Aravantinos G, Christodoulou C, Dimopoulos AM (2005) Postoperative dose-dense sequential chemotherapy with epirubicin, followed by CMF with or without paclitaxel, in patients with high-risk operable breast cancer: a randomized phase III study conducted by the Hellenic Cooperative Oncology Group. Ann Oncol Official J Eur Soc Med Oncol (ESMO) 16:1762–1771CrossRefGoogle Scholar
  15. 15.
    Gianni L, Norton L, Wolmark N, Suter TM, Bonadonna G, Hortobagyi GN (2009) Role of anthracyclines in the treatment of early breast cancer. J Clin Oncol Official J Am Soc Clin Oncol 27:4798–4808CrossRefGoogle Scholar
  16. 16.
    Hammond ME, Hayes DF, Dowsett M, Allred DC, Hagerty KL, Badve S, Fitzgibbons PL, Francis G, Goldstein NS, Hayes M, Hicks DG, Lester S, Love R, Mangu PB, McShane L, Miller K, Osborne CK, Paik S, Perlmutter J, Rhodes A, Sasano H, Schwartz JN, Sweep FC, Taube S, Torlakovic EE, Valenstein P, Viale G, Visscher D, Wheeler T, Williams RB, Wittliff JL, Wolff AC (2010) American society of clinical oncology/college of American pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer. J Clin Oncol Official J Am Soc Clin Oncol 28:2784–2795CrossRefGoogle Scholar
  17. 17.
    Henderson IC, Berry DA, Demetri GD, Cirrincione CT, Goldstein LJ, Martino S, Ingle JN, Cooper MR, Hayes DF, Tkaczuk KH, Fleming G, Holland JF, Duggan DB, Carpenter JT, Frei E 3rd, Schilsky RL, Wood WC, Muss HB, Norton L (2003) Improved outcomes from adding sequential Paclitaxel but not from escalating Doxorubicin dose in an adjuvant chemotherapy regimen for patients with node-positive primary breast cancer. J Clin Oncol Official J Am Soc Clin Oncol 21:976–983CrossRefGoogle Scholar
  18. 18.
    Hudis CA, Barlow WE, Costantino JP, Gray RJ, Pritchard KI, Chapman JA, Sparano JA, Hunsberger S, Enos RA, Gelber RD, Zujewski JA (2007) Proposal for standardized definitions for efficacy end points in adjuvant breast cancer trials: the STEEP system. J Clin Oncol Official J Am Soc Clin Oncol 25:2127–2132CrossRefGoogle Scholar
  19. 19.
    Kononen J, Bubendorf L, Kallioniemi A, Barlund M, Schraml P, Leighton S, Torhorst J, Mihatsch MJ, Sauter G, Kallioniemi OP (1998) Tissue microarrays for high-throughput molecular profiling of tumor specimens. Nat Med 4:844–847PubMedCrossRefGoogle Scholar
  20. 20.
    Laporte S, Jones S, Chapelle C, Jacquin J, Martín M (2009) Taxanes in adjuvant therapy—adjuvant chemotherapy consistency of effect of docetaxel-containing adjuvant chemotherapy in patients with early stage breast cancer independent of nodal status: meta-analysis of 12 randomized clinical trials. In: Thirty-second annual CTRC-AACR San Antonio breast cancer symposium. Cancer Research, San AntonioGoogle Scholar
  21. 21.
    Levine MN, Bramwell VH, Pritchard KI, Norris BD, Shepherd LE, Abu-Zahra H, Findlay B, Warr D, Bowman D, Myles J, Arnold A, Vandenberg T, MacKenzie R, Robert J, Ottaway J, Burnell M, Williams CK, Tu D (1998) Randomized trial of intensive cyclophosphamide, epirubicin, and fluorouracil chemotherapy compared with cyclophosphamide, methotrexate, and fluorouracil in premenopausal women with node-positive breast cancer. National cancer institute of canada clinical trials group. J Clin Oncol Official J Am Soc Clin Oncol 16:2651–2658Google Scholar
  22. 22.
    Liedtke C, Mazouni C, Hess KR, Andre F, Tordai A, Mejia JA, Symmans WF, Gonzalez-Angulo AM, Hennessy B, Green M, Cristofanilli M, Hortobagyi GN, Pusztai L (2008) Response to neoadjuvant therapy and long-term survival in patients with triple-negative breast cancer. J Clin Oncol Official J Am Soc Clin Oncol 26:1275–1281CrossRefGoogle Scholar
  23. 23.
    McShane LM, Altman DG, Sauerbrei W, Taube SE, Gion M, Clark GM (2005) Reporting recommendations for tumor marker prognostic studies. J Clin Oncol Official J Am Soc Clin Oncol 23:9067–9072CrossRefGoogle Scholar
  24. 24.
    Muller BM, Kronenwett R, Hennig G, Euting H, Weber K, Bohmann K, Weichert W, Altmann G, Roth C, Winzer KJ, Kristiansen G, Petry C, Dietel M, Denkert C (2011) Quantitative determination of estrogen receptor, progesterone receptor, and HER2 mRNA in formalin-fixed paraffin-embedded tissue–a new option for predictive biomarker assessment in breast cancer. Diagn Mol Pathol 20:1–10PubMedCrossRefGoogle Scholar
  25. 25.
    Nielsen TO, Hsu FD, Jensen K, Cheang M, Karaca G, Hu Z, Hernandez-Boussard T, Livasy C, Cowan D, Dressler L, Akslen LA, Ragaz J, Gown AM, Gilks CB, van de Rijn M, Perou CM (2004) Immunohistochemical and clinical characterization of the basal-like subtype of invasive breast carcinoma. Clin Cancer Res 10:5367–5374PubMedCrossRefGoogle Scholar
  26. 26.
    Parker JS, Mullins M, Cheang MC, Leung S, Voduc D, Vickery T, Davies S, Fauron C, He X, Hu Z, Quackenbush JF, Stijleman IJ, Palazzo J, Marron JS, Nobel AB, Mardis E, Nielsen TO, Ellis MJ, Perou CM, Bernard PS (2009) Supervised risk predictor of breast cancer based on intrinsic subtypes. J Clin Oncol Official J Am Soc Clin Oncol 27:1160–1167CrossRefGoogle Scholar
  27. 27.
    Pentheroudakis G, Batistatou A, Kalogeras KT, Kronenwett R, Wirtz RM, Bournakis E, Eleftheraki AG, Pectasides D, Bobos M, Papaspirou I, Kamina S, Gogas H, Koutras AK, Pavlidis N, Fountzilas G (2011) Prognostic utility of beta-tubulin isotype III and correlations with other molecular and clinicopathological variables in patients with early breast cancer: a translational Hellenic Cooperative Oncology Group (HeCOG) study. Breast Cancer Res Treat 127:179–193PubMedCrossRefGoogle Scholar
  28. 28.
    Rakha EA, El-Sayed ME, Green AR, Lee AH, Robertson JF, Ellis IO (2007) Prognostic markers in triple-negative breast cancer. Cancer 109:25–32PubMedCrossRefGoogle Scholar
  29. 29.
    Rouzier R, Perou CM, Symmans WF, Ibrahim N, Cristofanilli M, Anderson K, Hess KR, Stec J, Ayers M, Wagner P, Morandi P, Fan C, Rabiul I, Ross JS, Hortobagyi GN, Pusztai L (2005) Breast cancer molecular subtypes respond differently to preoperative chemotherapy. Clin Cancer Res 11:5678–5685PubMedCrossRefGoogle Scholar
  30. 30.
    Schippinger W, Dandachi N, Regitnig P, Hofmann G, Balic M, Neumann R, Samonigg H, Bauernhofer T (2007) The predictive value of EGFR and HER-2/neu in tumor tissue and serum for response to anthracycline-based neoadjuvant chemotherapy of breast cancer. Am J Clin Pathol 128:630–637PubMedCrossRefGoogle Scholar
  31. 31.
    Simon RM, Paik S, Hayes DF (2009) Use of archived specimens in evaluation of prognostic and predictive biomarkers. J Natl Cancer Inst 101:1446–1452PubMedCrossRefGoogle Scholar
  32. 32.
    Skacel M, Skilton B, Pettay JD, Tubbs RR (2002) Tissue microarrays: a powerful tool for high-throughput analysis of clinical specimens: a review of the method with validation data. Appl Immunohistochem Mol Morphol 10:1–6PubMedCrossRefGoogle Scholar
  33. 33.
    Tan DS, Marchio C, Jones RL, Savage K, Smith IE, Dowsett M, Reis-Filho JS (2008) Triple negative breast cancer: molecular profiling and prognostic impact in adjuvant anthracycline-treated patients. Breast Cancer Res Treat 111:27–44PubMedCrossRefGoogle Scholar
  34. 34.
    Tanner M, Gancberg D, Di Leo A, Larsimont D, Rouas G, Piccart MJ, Isola J (2000) Chromogenic in situ hybridization: a practical alternative for fluorescence in situ hybridization to detect HER-2/neu oncogene amplification in archival breast cancer samples. Am J Pathol 157:1467–1472PubMedCrossRefGoogle Scholar
  35. 35.
    Wolff AC, Hammond ME, Schwartz JN, Hagerty KL, Allred DC, Cote RJ, Dowsett M, Fitzgibbons PL, Hanna WM, Langer A, McShane LM, Paik S, Pegram MD, Perez EA, Press MF, Rhodes A, Sturgeon C, Taube SE, Tubbs R, Vance GH, van de Vijver M, Wheeler TM, Hayes DF (2007) American Society of Clinical Oncology/College of American Pathologists guideline recommendations for human epidermal growth factor receptor 2 testing in breast cancer. Arch Pathol Lab Med 131:18–43PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • P. Skarlos
    • 1
  • C. Christodoulou
    • 2
  • K. T. Kalogeras
    • 3
    • 4
  • A. G. Eleftheraki
    • 5
  • M. Bobos
    • 6
  • A. Batistatou
    • 7
  • C. Valavanis
    • 8
  • O. Tzaida
    • 8
  • E. Timotheadou
    • 4
  • R. Kronenwett
    • 9
    • 18
  • R. M. Wirtz
    • 9
    • 19
  • I. Kostopoulos
    • 10
  • D. Televantou
    • 6
  • E. Koutselini
    • 11
  • I. Papaspirou
    • 12
  • C. A. Papadimitriou
    • 13
  • D. Pectasides
    • 14
  • H. Gogas
    • 15
  • G. Aravantinos
    • 16
  • N. Pavlidis
    • 17
  • P. Arapantoni
    • 8
  • D. V. Skarlos
    • 2
  • G. Fountzilas
    • 4
  1. 1.Department of RadiotherapyAgios Savvas Cancer HospitalAthensGreece
  2. 2.Second Department of Medical OncologyMetropolitan HospitalPiraeusGreece
  3. 3.Translational Research Section, Hellenic Cooperative Oncology GroupData OfficeAthensGreece
  4. 4.Department of Medical Oncology, Papageorgiou HospitalAristotle University of Thessaloniki School of MedicineThessalonikiGreece
  5. 5.Section of Biostatistics, Hellenic Cooperative Oncology GroupData OfficeAthensGreece
  6. 6.Laboratory of Molecular Oncology, Hellenic Foundation for Cancer ResearchAristotle University of Thessaloniki School of MedicineThessalonikiGreece
  7. 7.Department of PathologyIoannina University HospitalIoanninaGreece
  8. 8.Department of PathologyMetaxas Cancer HospitalPiraeusGreece
  9. 9.Siemens Healthcare DiagnosticsCologneGermany
  10. 10.Department of PathologyAristotle University of Thessaloniki School of MedicineThessalonikiGreece
  11. 11.Department of PathologyMetropolitan HospitalPiraeusGreece
  12. 12.Department of PathologyAlexandra HospitalAthensGreece
  13. 13.Department of Clinical Therapeutics, Alexandra HospitalUniversity of Athens School of MedicineAthensGreece
  14. 14.Second Department of Internal Medicine, Oncology SectionHippokration HospitalAthensGreece
  15. 15.First Department of Medicine, Laiko General HospitalUniversity of Athens Medical SchoolAthensGreece
  16. 16.Third Department of Medical OncologyAgii Anargiri Cancer HospitalAthensGreece
  17. 17.Department of Medical OncologyIoannina University HospitalIoanninaGreece
  18. 18.Sividon Diagnostics GmbHCologneGermany
  19. 19.Stratifyer Molecular Pathology GmbHCologneGermany

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