Abstract
Purpose
Disseminated tumor cells (DTCs) in the bone marrow (BM) are known to be of prognostic value for patients with early breast cancer (EBC). In addition to histopathological features, multigene expression assays, such as the commercially available 21-gene Breast Recurrence Score® assay, have been validated for evaluating prognosis and making decisions concerning adjuvant treatment in EBC. In a previous retrospective study from our group, the 21-gene assay was shown to be associated with DTC-detection. A secondary endpoint of the prospective IRMA trial was to evaluate the association between Recurrence Score® (RS) result and tumor cell dissemination in patients with EBC.
Methods
DTC-status and RS result were assessed in patients with ER-positive/HER2-negative EBC with 0–3 pathologic lymph nodes who underwent primary surgical treatment at the Department for Women’s Health of Tuebingen University, Germany.
Results
Patients with a high RS result (≥ 26) were more frequently DTC-positive (22.6%) than patients with a low RS result (8.6%, p = 0.034). The odds for DTC-positivity increased with rising RS values (p = 0.047).
Conclusion
We therefore confirm that a high genomic risk is associated with tumor cell dissemination into the BM. Further trials are needed to investigate whether therapeutic decisions could be further individualized by combining DTC-status and prognostic gene signature testing.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
In the era of personalized medicine, decisions concerning adjuvant treatment and evaluations of prognosis are increasingly being based on molecular features of tumors. Particularly in early breast cancer (EBC), multigene expression assays have been validated for survival evaluation [1,2,3] and treatment decisions [4,5,6] in estrogen receptor (ER)-positive/HER2-negative tumors. Besides molecular characteristics of EBC, minimal residual disease (MRD) as detectable with the presence of disseminated tumor cells (DTCs) in the bone marrow (BM) is also known to be of prognostic value [7,8,9]. These DTCs, found in 20–30% of patients with EBC [10], are associated with a poorer outcome, as well as earlier locoregional and distant relapse in breast cancer patients [11, 12].
The commercially available 21-gene Oncotype DX Breast Recurrence Score® assay is already implemented in clinical routine [13,14,15,16,17]. In a retrospective study from our group, the 21-gene assay was shown to be associated with detection of DTCs in patients with ER-positive/HER2-negative EBC [18]. In patients with a Recurrence Score® (RS) result > 18, DTCs were detected more frequently than in those with a RS ≤ 18.
In the Impact of Recurrence Score® (RS) result on adjuvant treatment decisions and tumor cell dissemination in ER-positive and HER2-negative patients with early breast cancer (IRMA) trial, RS result and DTC-status were assessed prospectively [19]. This trial already demonstrated that by adding RS results to clinicopathological risk factors in ER-positive/HER2-negative EBC, treatment recommendations could be individualized and over- or undertreatment with adjuvant chemotherapy prevented [19].
A secondary endpoint of this trial was to validate the association between RS result and tumor cell dissemination.
Methods
Patients
IRMA is a prospective, monocentric investigator-initiated register study. It was approved by the Ethics Committee of Tuebingen University (789/2018BO2) and conducted according to the guidelines of the Declaration of Helsinki.
Patients who received primary surgery for hormone receptor (HR)-positive/HER2-negative, unilateral EBC (T1–4, N0–1) at Tuebingen University Women’s Hospital, Germany, were included in this study. HR-positive was defined as ER and/or progesterone receptor (PR) expression ≥ 10% according to immunohistochemical evaluation. HER2 status was assessed according to local standards by using the HERCEPT test (DAKO, Denmark). Expression of HER2 was scored on a 0 to + 3 scale. Tumors with a score of + 3 were considered HER2-positive. In case of a score of + 2, HER2 amplification was determined by fluorescence in situ hybridization using the Pathvysion® Kit (Vysis, Downers Grove, IL). Exclusion criteria were recurrent or metastatic disease, extensive lymph node involvement (> 3 positive lymph nodes, based on clinical or pathological status), neoadjuvant systemic therapy, bilateral breast cancer, or a previous history of malignancy.
DTC detection
For detecting DTCs, BM aspirates (10–20 ml) were collected during surgery for BC and processed within 24 h as described previously [20]. Briefly, mononuclear cells were separated by density centrifugation (Ficoll, 1.077 g/ml, Biochrom, Germany), spun down onto a glass slide (Hettich cytocentrifuge, Germany), and fixed in 4% formalin. Cytospins were stained using the DAKO Autostainer (Dako, Denmark) and a mouse monoclonal antibody directed against Keratin 8/18 Ab-1 (Thermo Fisher Scientific, Fremont, USA) was used. According to the consensus recommendations for standardized tumor cell detection [20], two slides with 1.5 × 106 cells per patient were evaluated after cytokeratin staining. Each batch of samples was analyzed together with leukocytes from healthy volunteers as negative controls and the human breast cancer cell lines MCF 7 and SKBR 3 as positive controls. DTC-positivity was defined as at least one cytokeratin-positive with abnormal cell morphology per 3.0 × 106 cells.
Assessment of 21-gene Breast Recurrence Score assay
Paraffin-embedded tumor tissue samples were submitted to Exact Sciences (Redwood City, CA, USA), according to guidelines provided by the manufacturer. The 21-gene Oncotype DX Breast Recurrence Score® assay (Exact Sciences, Redwood City, CA, USA) was assessed in all patients. Patients were divided into two groups, based on the RS-repartition of the TAILORx trial: 0–25 (RS low), 26–100 (RS high) [21].
Statistical analysis
Associations between nominally scaled independent variables were analyzed using the chi2-test. Normally distributed data was tested for significance using a two-sided Student’s t-test. The influence of continuous variations in the RS result on DTC status was assessed using logistic regression. Factors that achieved statistical significance with p < 0.05 in the univariate analysis for DTC positivity were assessed by using a multivariate logistic regression. Odds ratios (OR) and confidence intervals (CI) were calculated. All statistical tests were carried out with JMP 16 software 22 (SAS®). Significance level was set at p = 0.05.
Results
Patient characteristics
A total of 245 patients were included in the IRMA trial [19]. Among them, BM aspirates were available for 217 patients. Of all patients, 131 were postmenopausal (60.4%). Most tumors were histologically classified as non-special type (75.1%) and were grades 1–2 (83.4%). Around half of tumors were smaller than 20 mm (pT1, 52.1%). Also, the majorityshowed no lymph node involvement (69.6%).
DTCs were detected in 23 patients (10.6%). These findings were associated with tumor size: among patients with a tumor size < 20 mm a 6.2% DTC positivity was observed and among patients with larger tumors this rate was 15.4% (pT2-4, p = 0.027).
DTC-positive patients were more frequently treated with adjuvant chemotherapy (45.5% of DTC-positive patients vs. 24.0% of DTC-negative patients, p = 0.039). ki67 values did not differ between DTC-positive (mean ki67 (%): 20.6, SD ± 8.6) and DTC-negative patients (mean ki67 (%): 18.9, SD ± 11.7, p = 0.398).
The Oncotype DX® test yielded a median RS result of 15 (Q1–Q3: 10–21) with a low RS result (0–25) in 186 patients (85.7%) and a high RS result (26–100) in 31 (14.3%) patients. Recurrence Score result was associated with tumor size and grading: the percentage of patients with a high RS increased with tumor size (p = 0.016) and with grading (p < 0.001) with no patient simultaneously displaying a low grading and high RS result. Patients showing a RS result 26–100 more frequently received adjuvant chemotherapy (93.6% of patients with high RS result vs. 14.8% of patients with a low RS result, p < 0.001) (Table 1).
Comparison of DTC status and Recurrence Score result
Overall, 31 out of 217 patients (14.3%) showed a high RS result (RS 26–100). As displayed in Table 2, patients with a high RS result (26–100) were more frequently DTC-positive (22.6%) than patients with a low RS result (8.6%, p = 0.034). RS values were higher in DTC-positive (mean RS = 20.2, 95% CI 15.9–24.5) than in DTC-negative patients (mean RS = 16.3, 95% CI 15.0–17.6, t-test p = 0.048).
In the univariate analysis, the odds for DTC positivity significantly increased by 3.01% for a one-unit increase in RS result (95% CI 0.06–8.32, p = 0.047).
In the multivariate analysis, no significant association was found between clinical or histopathological parameter, RS result, and DTC status (see Table 3).
Discussion
In this study, we compared the results of the 21-gene assay with the DTC status in patients with ER-positive/HER2-negative EBC. To our knowledge, this is the largest prospective trial to date that addresses this question.
We found that DTCs were more frequently detected in patients with a high RS result, indicating that patients with a high RS result may more often be prone to early tumor cell dissemination. These results validate previous retrospective findings from our group [18]. Other studies addressed this question and did not find any correlation between RS result and DTC status [22, 23]. However, in those studies, the overall data were different: Aktas et al. reported that DTCs were detected in 36.5% out of 68 patients who underwent BM aspiration, whereas Singh et al. reported detecting DTCs in 34% of 58 patients included in their study [22, 23]. Both studies reported higher DTC positivity rates than in the largest pooled analysis known to date, in which about 23% of luminal-A-like patients were DTC-positive [11]. In the present study, DTCs were detected in 10.6% of patients, which was a low detection rate in this patient population. The low detection rate in our study is most likely due to the low-risk features of our cohort, with 69.6% patients being node-negative, 60.4% postmenopausal, 83.4% G1-2, and 52.1% with a tumor size < 20 mm. Indeed, 14.3% of the patients had a RS 26–100, which is similar to what was found in the TAILORx trial, [21]. In their study, Singh et al. performed DTC-detection using four more antibodies directed against cytokeratins, which offers a further explanation for the differences in DTC-detection rates [23].
In the multivariate analysis, we did not find a statistically significantassociation between RS result and DTC detection. Although DTC-positivity might be driven by larger tumor size, which was also correlated to RS results, the small sample size may have limited power to detect a statistically significant association between RS result and DTC positivity.
The Oncotype DX Breast Recurrence Score assay evaluates 16 cancer genes, some of which are associated with tumor proliferation and invasion. For instance, Stromelysin 3 (ST3) was shown to be expressed by breast cancer cells that have undergone epithelial-to-mesenchymal transition (EMT) [24] and to promote tumor cell migration [25]. Furthermore, secretion of cathepsins by breast cancer cells has been shown to regulate neutrophils, enabling formation of metastatic niches in the lung [26]. EMT as well as modification of the extracellular matrix and peritumoral milieu have also been reported to be associated with increased tumor cell dissemination in breast cancer [27, 28]. These findings may offer a molecular explanation for the association between high RS values and tumor cell dissemination into the BM.
The IRMA trial previously was able to show that by using RS for decisions concerning adjuvant chemotherapy treatment could be further individualized, mostly reducing recommendations for adjuvant chemotherapy [19]. However, a smaller group of patients was identified who might benefit from chemotherapy according to RS, although it was not initially recommended to them [19]. Until now, the information of DTC-status and RS have not been combined for adjuvant treatment decision.
Major limitations of the current study were the small patient population and the lower rate of DTC-positive patients compared to other studies. These factors may explain the lack of significance in the multivariate analysis and may also limit our ability to evaluate potential associations between RS results and DTC detection in subgroups of interest. Since these data were collected in the years 2018–2020, we are not yet able to present sufficient survival data in such a low-risk cohort.
In conclusion, we confirm that a high genomic risk is associated with tumor cell dissemination into the BM. The Oncotype DX Breast Recurrence Score® assay can identify patients with an increased risk of micrometastatic spread and tumor cell dormancy. Future trials should investigate whether therapeutic decisions could be further individualized by combining DTC detection and prognostic gene signature testing.
Data availability
The datasets generated during and/or analyzed during the current study are not publicly available for reasons of patient confidentiality but are available from the corresponding author on reasonable request.
References
Martin M et al (2014) Clinical validation of the EndoPredict test in node-positive, chemotherapy-treated ER+/HER2- breast cancer patients: results from the GEICAM 9906 trial. Breast Cancer Res 16(2):R38
Gnant M et al (2014) Predicting distant recurrence in receptor-positive breast cancer patients with limited clinicopathological risk: using the PAM50 Risk of Recurrence score in 1478 postmenopausal patients of the ABCSG-8 trial treated with adjuvant endocrine therapy alone. Ann Oncol 25(2):339–345
Paik S et al (2004) A multigene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer. N Engl J Med 351(27):2817–2826
Cardoso F et al (2016) 70-Gene signature as an aid to treatment decisions in early-stage breast cancer. N Engl J Med 375(8):717–729
Sparano JA et al (2020) Clinical outcomes in early breast cancer with a high 21-gene recurrence score of 26 to 100 assigned to adjuvant chemotherapy plus endocrine therapy: a secondary analysis of the TAILORx Randomized Clinical Trial. JAMA Oncol 6(3):367–374
Kalinsky K et al (2021) 21-Gene assay to inform chemotherapy benefit in node-positive breast cancer. N Engl J Med 385(25):2336–2347
Volmer L et al (2022) Neoadjuvant chemotherapy of patients with early breast cancer is associated with increased detection of disseminated tumor cells in the bone marrow. Cancers (Basel) 14(3):635
Stefanovic S et al (2016) Disseminated tumor cells in the bone marrow of patients with operable primary breast cancer: prognostic impact in immunophenotypic subgroups and clinical implication for bisphosphonate treatment. Ann Surg Oncol 23(3):757–766
Hartkopf AD et al (2013) The presence and prognostic impact of apoptotic and nonapoptotic disseminated tumor cells in the bone marrow of primary breast cancer patients after neoadjuvant chemotherapy. Breast Cancer Res 15(5):R94
Braun S et al (2005) A pooled analysis of bone marrow micrometastasis in breast cancer. N Engl J Med 353(8):793–802
Hartkopf AD et al (2021) Disseminated tumour cells from the bone marrow of early breast cancer patients: results from an international pooled analysis. Eur J Cancer 154:128–137
Hartkopf AD et al (2015) Disseminated tumor cells from the bone marrow of patients with nonmetastatic primary breast cancer are predictive of locoregional relapse. Ann Oncol 26(6):1155–1160
Ditsch N et al (2021) AGO recommendations for the diagnosis and treatment of patients with early breast cancer: update 2021. Breast Care (Basel) 16(3):214–227
Reyes SA et al (2019) Practice changing potential of TAILORx: a retrospective review of the National Cancer Data Base from 2010 to 2015. Ann Surg Oncol 26(10):3397–3408
Christgen M et al (2020) Differential impact of prognostic parameters in hormone receptor-positive lobular breast cancer. Cancer 126(22):4847–4858
Thill M et al (2020) The REMAR (Rhein-Main-Registry)-Study: prospective evaluation of oncotype DX (R) assay in addition to Ki-67 for adjuvant treatment decisions in early breast cancer. Eur J Cancer 138:S92–S93
Stemmer SM et al (2017) Clinical outcomes in ER+ HER2 -node-positive breast cancer patients who were treated according to the Recurrence Score results: evidence from a large prospectively designed registry. NPJ Breast Cancer 3:32
Hartkopf AD et al (2016) Detection of disseminated tumor cells from the bone marrow of patients with early breast cancer is associated with high 21-gene recurrence score. Breast Cancer Res Treat 156(1):91–95
Danneh D et al (2022) Recurrence Score((R)) result impacts treatment decisions in hormone receptor-positive, HER2-negative patients with early breast cancer in a real-world setting-results of the IRMA trial. Cancers (Basel) 14(21):5365
Fehm T et al (2006) A concept for the standardized detection of disseminated tumor cells in bone marrow from patients with primary breast cancer and its clinical implementation. Cancer 107(5):885–892
Sparano JA et al (2018) Adjuvant chemotherapy guided by a 21-gene expression assay in breast cancer. N Engl J Med 379(2):111–121
Aktas B et al (2013) Evaluation and correlation of risk recurrence in early breast cancer assessed by Oncotype DX((R)), clinicopathological markers and tumor cell dissemination in the blood and bone marrow. Mol Clin Oncol 1(6):1049–1054
Singh P et al (2020) Correlation of circulating or disseminated tumor cells with the Oncotype DX Recurrence Score. Breast Cancer Res Treat 184(3):683–687
Ahmad A et al (1998) Stromelysin 3: an independent prognostic factor for relapse-free survival in node-positive breast cancer and demonstration of novel breast carcinoma cell expression. Am J Pathol 152(3):721–728
Kang SU et al (2022) Matrix metalloproteinase 11 (MMP11) in macrophages promotes the migration of HER2-positive breast cancer cells and monocyte recruitment through CCL2-CCR2 signaling. Lab Invest 102(4):376–390
Kos K, de Visser KE (2021) Neutrophils create a fertile soil for metastasis. Cancer Cell 39(3):301–303
Paolillo M, Schinelli S (2019) Extracellular matrix alterations in metastatic processes. Int J Mol Sci 20(19):4947
Mego M et al (2020) Circulating tumor cells and breast cancer-specific mutations in primary breast cancer. Mol Clin Oncol 12(6):565–573
Acknowledgements
This study was supported by Exact Sciences Inc., Redwood City, CA, USA
Funding
Open Access funding enabled and organized by Projekt DEAL. This study was supported by Exact Sciences Inc., Redwood City, CA, USA.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing interests
F.-A.T. received honoraria from Novartis, Tesaro, Gilead, Genomic Health, Roche, Hexal, Astra Zeneca, Pfizer, GSK, MSD. D.D. received travel tupport from Daiichi Sankyo and Gilead. S.Y.B. received honoraria from AstraZeneca, Roche, Novartis, Medtronic, Sanofi, Lilly, MSD and Hologic. The other authors have no relevant financial or nonfinancial interests to disclose.
Ethical approval
This study was conducted according to the guidelines of the Declaration of Helsinki. It was approved by the Ethics Committee of Tuebingen University (789/2018BO2).
Consent to participate
Informed consent was obtained from all individual participants included in the study.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Volmer, L.L., Dannehl, D., Engler, T. et al. Association between 21-gene-assay and detection of disseminated tumor cells in patients with early breast cancer: results from the IRMA trial. Breast Cancer Res Treat 202, 67–72 (2023). https://doi.org/10.1007/s10549-023-07031-w
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10549-023-07031-w