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Disseminated tumour cells in the bone marrow in early breast cancer: morphological categories of immunocytochemically positive cells have different impact on clinical outcome

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Abstract

Detection of disseminated tumour cells (DTCs) in bone marrow by immunocytochemistry (ICC) includes morphological evaluation of cytokeratin immunopositive cells. The aim of this study was to disclose the prognostic significance of different morphological categories of ICC-positive cells according to treatment status and tumour subtype. Bone marrow samples (at surgery) were analysed for the presence of cytokeratin-positive DTCs by a standard immunocytochemical method. The immunopositive cells were classified into the following categories, prior to any analysis of the association between DTCs and clinical outcome: tumour cells (TC), uninterpretable cells (UIC), hematopoietic cells (HC), and questionable HC (QHC). The analysis included 747 early breast cancer patients. Median follow-up was 84 months for relapse, and 99 months for death. The categorisation of the ICC positive cells revealed TC in 13.3 % of the patients, whereas 13.1, 17.8, and 21.4 % of the cases were positive for UIC, QHC, and HC, respectively. Analysing all patients, only TC and UIC predicted systemic relapse. Separate analysis of all patients not receiving adjuvant systemic treatment (No-Adj; n = 389) showed that only QHC were associated with reduced survival (DDFS: p = 0.008; BCSS: p = 0.004, log rank) and the presence of QHC also remained significant in multivariate analysis. Primary tumour subgroup analysis (of all patients) by hormone receptors (HR) and HER2, demonstrated that only TC/UIC had prognostic impact in the HR+/HER2− patients, whereas presence of QHC was associated with unfavourable outcome only in triple negative patients (DDFS: p = 0.004; BCSS: p = 0.024). Patients with ≥3HC had improved outcome compared to those with fewer/no HC (DDFS: p = 0.005; BCSS: p = 0.009). Hence, morphological DTC subgroups may differ in clinical significance according to primary tumour subtype and treatment status. This emphasises the importance of DTC characterisation, and separate analyses of DTC categories according to tumour subtype. Hematopoietic (“false positive”) cells might predict an immune-related favorable clinical outcome.

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Abbreviations

DTCs:

Disseminated tumour cells

BM:

Bone marrow

FU:

Follow-up

ICC:

Immunocytochemical analysis

MNC:

Mononuclear cells

APAAP:

Alkaline phosphatase/monoclonal mouse anti-alkaline phosphatase

HC:

Hematopoietic cells

TC:

Tumour cells

UIC:

Uninterpretable cells

pT:

Histopathological primary tumor size status

pN:

Histopathological lymph node status

G1, 2, 3:

Histopathological grade 1–3

IHC:

Immunohistochemical staining

ER:

Estrogen receptor(s)

PR:

Progesteron receptor(s)

HER2:

Human epidermal growth factor receptor 2

TMA:

Tissue microarray

FISH:

Fluorescence in situ hybridization

QHC:

Questionable hematopoietic cells

BCSS:

Breast cancer-specific survival

DDFS:

Distant disease-free survival

HR:

Hormone receptor(s)

TN:

Triple negative

CTCs:

Circulating tumour cells

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Acknowledgments

We thank the staff at The Micrometastasis Laboratory, Department of Pathology, Radiumhospitalet, for their excellent technical assistance. The study was supported by The Research Council of Norway, South-Eastern Norway Regional Health Authority, The Norwegian Cancer Society, K. G. Jebsen Centre for Breast Cancer Research, and the European Commission within the 7th Framework Programme (The Miracle project).

Conflict of interest

The authors declare no conflicts of interests.

Author information

Authors and Affiliations

  1. Division of Surgery and Cancer Medicine, Department of Oncology, Oslo University Hospital, Radiumhospitalet, Postboks 4953 Nydalen, 0424, Oslo, Norway

    M. Synnestvedt & B. Naume

  2. Department of Pathology, Oslo University Hospital, Radiumhospitalet, Oslo, Norway

    E. Borgen, C. B. Schirmer, A. Renolen & J. M. Nesland

  3. Department of Surgery, Oslo University Hospital, Ullevål, Oslo, Norway

    E. Schlichting

  4. Department of Surgery, Oslo University Hospital, Radiumhospitalet, Oslo, Norway

    K. E. Giercksky

  5. Institute of Clinical Medicine, University of Oslo, Oslo, Norway

    K. E. Giercksky & J. M. Nesland

  6. K.G. Jebsen Centre for Breast Cancer Research, Institute for Clinical Medicine, University of Oslo, Oslo, Norway

    B. Naume

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  1. M. Synnestvedt
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  2. E. Borgen
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  5. A. Renolen
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Correspondence to B. Naume.

Additional information

Synnestvedt and Borgen contributed equally to the manuscript.

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Supplementary Table 1

Cox multivariate analysis in patients receiving adjuvant systemic treatment (Adj). (DOC 35 kb)

Supplementary Table 2

Cox multivariate analysis. Prognostic significance of DTC categories according to primary tumour subgroups. (DOC 60 kb)

Supplementary Fig. 1

Survival analyses (DDFS and BCSS) for patients with (Pos) or without (Neg) QHC detected in the BM; for all No-Adj patients, and for all TN patients; only patient samples including ≥1.5x106 cells in the negative control included. P values were computed by log-rank test. (TIFF 510 kb)

Supplementary Fig. 2

Distant disease-free survival among No-Adj patients with (Pos) or without (Neg) the indicated DTC subcategory (TC versus UIC versus QHC) detected in the BM; for No-Adj HR +/HER2- patients, for No-Adj HER2 + patients (HR- or +) and for No-Adj TN patients. Due to missing data in the database for a few patients, the number of patients included in the various survival analyses differ. (TIFF 747 kb)

Supplementary Fig. 3

Breast cancer-specific survival among No-Adj patients with (Pos) or without (Neg) the indicated DTC subcategory (TC versus UIC versus QHC) detected in the BM; for No-Adj HR +/HER2- patients, for No-Adj HER + patients (HR- or +) and for No-Adj TN patients. Due to missing data in the database for a few patients, the number of patients included in the various survival analyses differ. (TIFF 721 kb)

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Synnestvedt, M., Borgen, E., Schlichting, E. et al. Disseminated tumour cells in the bone marrow in early breast cancer: morphological categories of immunocytochemically positive cells have different impact on clinical outcome. Breast Cancer Res Treat 138, 485–497 (2013). https://doi.org/10.1007/s10549-013-2439-8

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