Outcome Of Triple-negative Breast Cancer Patients Research Articles

Abstract ES6-1: ES6-1 Assessment of residual disease and treatment implications post neoadjuvant therapy

Abstract Breast cancer is a highly heterogeneous disease with various molecular subtypes that differ in regard to treatment approach as well as unresolved treatment issues. In women with HER2-amplified breast tumors, standard neoadjuvant therapy consisting of dual HER2 blockade with trastuzumab/pertuzumab plus chemotherapy can induce a high pathologic complete response (pCR) rate (60%), which translates into better overall survival (>90% at 3 years). A critical unresolved issue in the neoadjuvant treatment of HER2-amplified tumors is minimizing toxicity in select patients. Selection of non-cardiogenic regimens and chemotherapy-free or lighter chemotherapy regimens should be the focus for women whose disease is highly addicted to the HER2 pathway. New research directions are also exploring ways to minimize the extent of local surgery in the breast and axilla. Approximately 30% of patients with triple-negative breast cancer (TNBC) achieve pCR after neoadjuvant chemotherapy. While these patients tend to have a favorable prognosis, those with residual disease (RD) at the time of surgical resection may expect significantly worse outcomes and, at present, do not have targeted therapeutic options. Molecular analysis of tumor tissue from such patients may be used to identify the genetic alterations responsible for disease recurrence and to help individualize treatment with available agents. Transcriptome and sequencing analyses have identified important pathways and aberrations in the majority of residual tumors. Targeting these molecular abnormalities in conjunction with the tumor immune microenvironment may represent an effective therapeutic avenue to improve the outcomes of TNBC patients who have RD after standard neoadjuvant therapy. Adaptive clinical trials investigating neoadjuvant treatments directed against key pathways active in residual tumors are underway. Citation Format: Chang JC. ES6-1 Assessment of residual disease and treatment implications post neoadjuvant therapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr ES6-1.

Abstract P2-04-16: CD103+/PD-1+ T-cells identify a subset of triple-negative breast cancer eligible for targeted checkpoint inhibition

Abstract Background: The presence of tumor-infiltrating lymphocytes (TILs) is a prognostic factor in triple-negative breast cancer (TNBC). In particular, cytotoxic CD8+ cells are associated with favorable outcome in TNBC. Recently, the integrin CD103 have been suggested as a potential prognostic marker in a small cohort of triple-negative/basal-like breast cancer (Wang et al, Clin Cancer Res 2016). In this study, we aimed to evaluate the functional status and clinical relevance of CD8+ and CD103+ TILs in TNBC. Methods: A large collection of formalin-fixed, paraffin-embedded tissues was retrospectively collected from 210 patients with primary invasive ductal TNBC. The presence of CD8, CD103 and the checkpoint receptor PD-1 was assessed by immunohistochemistry. Whole tumor slides were independently assessed by two pathologists blinded for patient characteristics and outcome. Cases where ≥5% of TILs expressed CD103 or PD-1 were considered positive. Statistical analyses were performed using Spearman's correlation, Kaplan-Meier and Cox regression analyses. Results: We found that CD103+ cells mostly co-expressed the CD8 marker, and were preferentially distributed within tumor epithelium. No consistent correlation was found between the presence of CD103+ lymphocytes and the expression of its ligand E-cadherin by TNBC cells (rs=0.365). CD8+ lymphocytes were consistently associated with better relapse-free survival (RFS) and overall survival (OS) in both univariate (HR=0.61; P=1.06E-02 for RFS; HR=0.59; P=1.93E-02 for OS) and multivariate analysis (HR=0.65; P=2.45E-02 for RFS; HR=0.63; P=3.96E-02 for OS). The presence of CD103+ lymphocytes significantly correlated with prolonged RFS and OS in univariate analysis only (HR=0.82; P=4.12E-02 for RFS; HR=0.85; P=4.93E-02 for OS), and a trend for longer RFS was also observed in univariate analysis for PD-1 (HR=0.71; P=5.22E-02). Interestingly, a subset of TNBC showed co-expression of CD103+/PD-1+ in lymphocytes localized to the intraepithelial areas of the tumor. Conclusions: The expression of CD103 on CD8+ T cells in direct contact with cancer cells may identify a subpopulation of cells with potent cytolytic activity. The interaction between CD103+ cytotoxic lymphocytes and cancer cells is mediated by mechanisms other than the binding to E-cadherin. Even though CD103 has a role in mediating an effective anti-tumor immune response, its presence alone may not be sufficient to impact the outcome of TNBC patients. Immunomodulatory therapies may be useful to boost the anti-tumor activity of potentially quiescent CD103+/PD-1+ cells in a subgroup of TNBC. Citation Format: Bottai G, Loi S, Sotiriou C, Roncalli M, Pusztai L, Reis-Filho JS, Santarpia L. CD103+/PD-1+ T-cells identify a subset of triple-negative breast cancer eligible for targeted checkpoint inhibition [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-04-16.

MiRNAs Predict the Prognosis of Patients with Triple Negative Breast Cancer: A Meta-Analysis.

PurposemiRNAs are stable and can be extracted from tissues, blood and other body fluid without degradation. miRNAs are abnormally expressed in the presence of a pathological status, including cancer. Therefore, miRNAs are ideal biomarkers for cancer diagnosis and prognosis. Patients with triple negative breast cancer (TNBC) suffer the worst prognosis, although great efforts have been made. Many studies have investigated the role of miRNAs in predicting the outcomes of TNBC patients for better adjustment of treatment. However, results were inconsistent. Thus, we performed a meta-analysis to summarize the published studies for conclusive results.MethodsEligible studies from different database were retrieved from the online databases, and we used STSTA 12.0 to analysis the prognostic role of miRNAs in triple negative breast cancer.ResultsOverall high miRNA expression indicated a worse survival with HR value of 1.78 (95% CI: 0.97–3.25). However, subtotal HRs of oncogenic miRNAs and tumor suppressive miRNAs were 2.73 (95% CI: 2.08–3.57; P<0.001) and 0.44 (95% CI: 0.21–0.90; P = 0.024), respectively, and no heterogeneity was observed within the subgroups.ConclusionsThe miRNAs showed a slightly stronger prognostic value for disease-free survival, relapse-free survival and distant metastasis-free survival compared to the overall survival of TNBC patients. Circulating miRNAs could serve as potential biomarkers for the prognosis of TNBC patients and need further investigation.

Tackling intra- and inter-tumor heterogeneity to combat triple negative breast cancer.

Rampant inter-patient and intra-tumor heterogeneity present formidable challenges in the clinical management of triple-negative breast cancer (TNBC) and mandate a "divide-and-conquer" approach wherein deep biomarker profiling drives patient segmentation and development of customized treatments. Genomic and proteomic studies have uncovered several TNBC subtypes each of which represents a distinct disease pathobiology and harbors unique actionable targets that may illuminate sensitivities to specific classes of therapeutics. This review details the mind-boggling complexity of TNBC, its ramifications for prognosis and therapeutic response, and discusses what treatments might befit each TNBC subtype. Additionally, focused efforts geared toward translating these findings into the clinic are urged. This review also supports an evidence-based paradigm shift towards inclusion of agents that target the mechanisms that drive intra-tumor heterogeneity, in order to improve long-term outcomes for TNBC patients.

Abstract A118: CD103+/PD-1+ T-cells identify a subset of triple-negative breast cancer eligible for targeted checkpoint inhibition

Abstract The presence of tumor-infiltrating lymphocytes (TILs) is a prognostic factor in triple-negative breast cancer (TNBC). Specifically, cytotoxic CD8+ cells are associated with favorable outcome in TNBC. Recently, the integrin CD103 has been suggested as a potential prognostic marker in breast cancer. In this study, we aimed to evaluate the functional status and clinical relevance of CD8+ and CD103+ TILs in TNBC. A retrospective cohort of 210 formalin-fixed, paraffin-embedded tissues from patients with primary invasive ductal TNBC was assessed for the presence of CD8, CD103 and the checkpoint receptor PD-1 by immunohistochemistry assay. Whole tumor slides were assessed. Cases where ≥5% of TILs expressed CD103 or PD-1 were considered positive. Statistical analyses were performed using Spearman's correlation, Kaplan-Meier and Cox regression analyses. We found that CD103+ cells mostly co-expressed the CD8 marker, and were preferentially distributed within tumor epithelium. No consistent correlation was found between the presence of CD103+ lymphocytes and the expression of its ligand E-cadherin by TNBC cells (rs = 0.365). CD8+ lymphocytes were consistently associated with better relapse-free survival (RFS) and overall survival (OS) in both univariate (HR = 0.61; P = 1.06E-02 for RFS; HR = 0.59; P = 1.93E-02 for OS) and multivariate analysis (HR = 0.65; P = 2.45E-02 for RFS; HR = 0.63; P = 3.96E-02 for OS). The presence of CD103+ lymphocytes significantly correlated with prolonged RFS and OS in univariate analysis only (HR = 0.82; P = 4.12E-02 for RFS; HR = 0.85; P = 4.93E-02 for OS), and a trend for longer RFS was also observed in univariate analysis for PD-1 (HR = 0.71; P = 5.22E-02). Interestingly, a subset of TNBC showed co-expression of CD103+/PD-1+ in lymphocytes localized to the intraepithelial areas of the tumor. The expression of CD103 on CD8+ T cells in direct contact with cancer cells may identify a subpopulation of cells with potent cytolytic activity. The interaction between CD103+ cytotoxic lymphocytes and TNBC cells is mediated by different mechanisms rather than the binding to E-cadherin. Even though CD103 has a role in mediating an effective anti-tumor immune response, its presence alone may not be sufficient to impact the outcome of TNBC patients. Immunomodulatory therapies may be useful to boost the anti-tumor activity of potentially quiescent CD103+/PD-1+ cells in a subgroup of TNBC patients. Citation Format: Giulia Bottai, Massimo Roncalli, Libero Santarpia. CD103+/PD-1+ T-cells identify a subset of triple-negative breast cancer eligible for targeted checkpoint inhibition [abstract]. In: Proceedings of the Second CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; 2016 Sept 25-28; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(11 Suppl):Abstract nr A118.

Nomograms for Predicting the Prognostic Value of Pre-Therapeutic CA15-3 and CEA Serum Levels in TNBC Patients

Previous studies have indicated that carcinoembryonic antigen (CEA) and cancer antigen 15–3 (CA15-3) levels are both independent prognostic factors in breast cancer. However, the utility of CEA and CA15-3 levels as conventional cancer biomarkers in patients with triple-negative breast cancer (TNBC) remains controversial. The current study was performed to explore the predictive value of pre-therapeutic serum CEA and CA15-3 levels, and nomograms were developed including these serum cancer biomarkers to improve the prognostic evaluation of TNBC patients. Pre-therapeutic CA15-3 and CEA concentrations were measured in 247 patients with stage I–IV TNBC. Kaplan-Meier analysis showed that TNBC patients with high levels of both CEA and CA15-3 had shorter overall survival (OS) and disease-free survival (DFS) rates than those in the low-level groups (p<0.05). Multivariate analysis suggested that pre-therapeutic CA15-3 and CEA levels are independent predictive elements for OS (p = 0.022 and p = 0.040, respectively) and DFS (p = 0.023 and p = 0.028, respectively). In addition, novel nomograms were established and validated to provide personal forecasts of OS and DFS for patients with TNBC. These novel nomograms may help physicians to select the optimal treatment plans to ensure the best outcomes for TNBC patients.

Clinical characteristics of triple negative breast cancer in Egyptian women: a hospital-based experience

Purpose: Triple negative breast cancer (TNBC) is an aggressive subtype of breast cancer with poor prognosis despite the high rates of response to chemotherapy. We aim to study the clinical features, factors influencing recurrence and survival outcomes of TNBC patients. Methods: We retrospectively studied the charts of patients with biopsy proven TNBC treated at The Clinical Oncology Department Ain-Shams University between 2009 and 2012. Results: One hundred and forty five patients fulfilled the eligibility criteria. The incidence of TNBC was 10.5% - 15% with a mean of 12% of all breast cancer patients. The follow-up duration ranged from six months to four years. The age range was 26 to 78 years. Infiltrating ductal carcinoma represented 93.1% of the pathologic types. 87% of patients were free of metastases (M0) at presentation. Clinical stages II and III represented 38 and 39.5% of the patients. 66% of patients had modified radical mastectomy. Following surgery, 77.5% of patients received adjuvant chemotherapy while 61% of the patients had adjuvant radiation therapy. Anthracyclines based chemotherapy was given to 52% of patients. Disease-free survival (DFS) of the M0 patients at 20 and 30 months was 92% and 80% respectively. Relapse occurred in 23% of M0 patients. After a mean duration of DFS of 15.1 months, the most common sites of metastases for relapsed M0 patients were pulmonary (44.8%), bone (41.4%), and locoregional (13.8%). The median overall survival (ORS) of patients was 18 months (1 - 45 months), whereas for the M1 group of patients the median ORS was 9 months (2 - 29 months). Conclusion: The incidence, pathological characteristics, and clinical behavior of TNBC were similar to what is mentioned in the literature. Adding taxanes to the chemotherapy protocols and using postoperative radiotherapy were both associated with a significant increase in the mean period of DFS, while did not significantly affect the ORS.

A meta-analysis of biomarkers for the prognosis of triple-negative breast cancer patients.

Identification of biomarkers that has the ability to predict triple-negative breast cancer (TNBC) prognosis especially in patients undergoing chemotherapy is very important. The cohort studies that reported association between chemotherapy biomarker expression and survival outcome in TNBC patients were included in our analysis. The promising markers that emerged for the prediction of disease-free survival and overall survival included Ki67, BRCA1 methylation and LC3B. Furthermore, Ki67 appeared to be also significantly associated with worse disease-free survival in TNBC patients who received anthracycline-based chemotherapy. This meta-analysis demonstrated that in TNBC patients receiving chemotherapy, Ki67 is a predictor for poor prognosis, BRCA1 methylation and LC3B are also potential prognostic markers. In addition, the TNBC patients with high Ki67 expression seems to display resistance to anthracycline-based chemotherapy.

The significant prognostic value of circulating tumor cells in triple-negative breast cancer: a meta-analysis.

BackgroundThe clinical validity of circulating tumor cells (CTCs) is still controversial in patients with triple-negative breast cancer (TNBC).MethodsA comprehensive literature search was performed to identify relevant articles in the PubMed, Web of Science, MEDLINE, and Embase databases through September 2015. The outcomes of interest were disease progression and overall survival. The hazard ratio (HR) and 95% confidence interval (95% CI) were considered the effect indicators and were pooled in meta-analyses under a fixed- or random-effect model according to heterogeneity.ResultsTen of the eligible studies were included for a total of 642 enrolled TNBC patients. Overall analyses revealed that the presence of CTCs predicted aggressive disease progression (HR = 2.18, 95% CI = 1.59-2.99, Pheterogeneity = 0.010, I2 = 52.2%) and reduced overall survival (HR = 2.02, 95% CI = 1.59-2.57, Pheterogeneity = 0.169, I2 = 26.6%). Further subgroup analyses demonstrated that CTC-positive patients also had poor disease progression and overall survival in different subsets, including cancer stage.ConclusionOur meta-analysis provides strong evidence that detection of CTC in the peripheral blood is an independent prognosticator of poor survival outcomes for TNBC patients.

Abstract P6-13-09: Dual PI3K and Wnt pathway inhibition is a synergistic combination against triple negative breast cancer

Abstract Introduction: Triple negative breast cancer (TNBC) accounts for 15% of all breast cancer cases in the United States, and despite its lower incidence, contributes to a disproportionately higher rate of morbidity and mortality compared to other breast cancer subtypes. Because these tumors lack expression of the estrogen, progesterone, or HER-2 receptors ("triple negative"), TNBC patients do not respond to targeted therapies that have been successfully used against tumors that over-express these proteins. Thus, there exists a critical need to improve the outcomes of TNBC patients through the implementation of novel targeted agents. Methods: RNA-seq data from 94 TNBCs (from Indiana University and TCGA) and 20 microdissected normal breast tissues (Komen Tissue Bank) were merged and analyzed using Partek Genomics Suite. Statistically significant genes were imported into Ingenuity Pathway Analysis (IPA) to identify therapeutic targets. For in vitro studies, we tested a panel of TNBC cell lines using Buparlisib (a PI3K pathway inhibitor) and WNT974 (a WNT pathway inhibitor), individually and in combination. Cell viability was assessed via Celltiter-Fluor. Synergy between the two drugs was calculated using the Chou-Talalay method. In vivo studies were performed using the TMD-231 cell line and a patient derived xenograft (PDX) from the Jackson Laboratory. Dosing of the mice was performed using 30 mg/kg and 3 mg/kg of Buparlisib and WNT974 respectively, both in combination and individually. Results: Using next-generation RNA sequencing data of TNBCs and microdissected normal breast tissue, Ingenuity Pathway Analysis identified over-expression and hyper-activation of the PI3K/AKT/mTOR pathway. When treating cell lines with the PI3K inhibitor Buparlisib, RNA sequencing revealed compensatory induction of the WNT pathway across TNBC cell lines. In particular, we observed induction of Porcupine, a Wnt maturation protein, which is the protein target of the Wnt pathway inhibitor, WNT974. When anti-tumor efficacy against these pathways was assessed, a significant reduction in cell viability using Buparlisib and WNT974 in combination was observed. Using the Chou-Talalay method, we found for MDA-MB-231 and Hs578T cell lines, a ∼50% reduction in cell viability at 100nM concentration of each drug that was highly synergistic (Combination Index = 0.33, and 0.36 respectively). In our in vivo PK study of the combination, there was no drug-drug interaction observed. Furthermore, in our PD analysis using a TMD-231 xenograft, we observed a ∼40% reduction in tumor volume after seven days. In a subsequent in vivo PDX experiment, we observed an 80% survival rate using combination therapy compared to 40% when administering the drugs individually or with vehicle control after 30 days. Conclusion: PI3K/mTOR/AKT and Wnt pathways are strong candidates for the development of novel targeted agents for TNBC. Using two small molecule inhibitors that are currently in clinical trials as single agents (Buparlisib and WNT974) we observe significant in vitro synergy when inhibiting both pathways at low nanomolar doses. Furthermore, confirmatory in vivo xenograft studies display a similar synergy for the combination compared to single agent and vehicle controls. Citation Format: Solzak JP, Atale R, Hancock B, Radovich M. Dual PI3K and Wnt pathway inhibition is a synergistic combination against triple negative breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-13-09.

Pretreatment TG/HDL-C Ratio Is Superior to Triacylglycerol Level as an Independent Prognostic Factor for the Survival of Triple Negative Breast Cancer Patients.

Purpose: Previous studies have reported that the triacylglycerol (TG) level and high-density lipoprotein cholesterol (HDL-C) are connected with breast cancer. However, the prognostic utility of the TG level and the TG/HDL-C ratio (THR) as conventional biomarkers in patients with triple negative breast cancer (TNBC) has not been elucidated. In this research, we investigate and compare the predictive value of the pretreatment serum TG level and THR in TNBC patients.Methods: We evaluated 221 patients with TNBC who had pretreatment conventional blood biochemical examinations and calculated the THR. Univariate and multivariate logistic regression analyses were used to assess the effect of the TG level and the THR on overall survival (OS) and disease-free survival (DFS).Results: The optimal cutoff values of the TG level and the THR were determined to be 0.935 mmol/L and 0.600, respectively. As shown in a Kaplan-Meier analysis, TNBC patients with a high TG level and THR had shorter OS and DFS than patients in the low-level groups (p < 0.05). The multivariate analysis suggested that the pretreatment THR level is an independent prognostic factor of OS (HR: 1.935; 95%CI: 1.032-3.629; p = 0.040) in TNBC patients.Conclusions: In conclusion, our data indicate that a high THR is an independent predictor and is superior to the TG level for predicting poor clinical outcomes in TNBC patients.

Survival outcomes in Egyptian patients with triple-negative breast cancer: Single institute experience.

158 Background: Triple-negative breast cancer (TNBC) is a unique subtype and consider as an aggressive disease without established targeted treatment options. This study conducted to determine the incidence, characteristics, and survival outcomes of TNBC patients in an Egyptian cancer institute. Methods: Medical records of 520 patients treated between 2010-2011 in Clinical Oncology Department-Ain Shams University-Egypt were analyzed. Cox proportional hazards models were used to evaluate the association between TNBC and DFS and OS after adjusting for other covariates. Results: Among the 520 patients, 139 were TNBC .The median age was 50 years (SD±11.767, Range 20-80 ) versus 52 years (SD±12.134, Range 20-80), median tumor diameter was 5 cm (SD± 1.408, Range 1-7) versus was 5 cm (SD± 1.401, Range 1-7) , and median number of positive axillary LN was 3 (SD± 4.779, Range 0-37) versus 3 (SD± 4.832, Range 0-25) in non TNBC and TNBC respectively . Median disease-free survival was 24 months (SD± 14.128, Range 1-69 ) versus 15 months (SD± 8.811, Range 1-43 ) and median overall survival was 41 months (SD± 16.249, Range 3-60) versus 31 months (SD± 12.184, Range 7-60 ) in non TNBC and TNBC respectively. About 85.6 % of the TNBC tumors were IDC, 4.4 % were ILC and 5% were mixed. About 1.4 % of the TNBC tumors were grade I, 70.5 % were grade II and 28.1% were grade III. Median disease-free survival was 24 months (95%CI 21.679- 26.321) versus 15 months (95%CI 12.587-17.413) (p&lt; 0.001) and median overall survival was 44 months (95%CI 41.396-46.604) versus 31 months (95%CI 29.460-32.540) (p&lt; 0.001) in non TNBC and TNBC respectively. In TNBC cohort , DFS was 12 months (95%CI 11.464-12.536) in patients with grade III tumors versus 25 months (95%CI 22.359-27.641 )in patients with other grades (p&lt; 0.001), this was also reflected in OS as 29 months (95%CI 25.129-32.871 ) versus 44 months (95%CI 41.238-46.762 ) (p&lt; 0.001). Conclusions: Multivariate analyses supported a conclusion that TNBC subtype was an independent adverse prognostic factor for survival along with other known risk factors such as tumor grade.

Stratifying triple-negative breast cancer prognosis using 18F-FDG-PET/CT imaging.

This study aims to stratify prognosis of triple-negative breast cancer (TNBC) patients using pre-treatment 18F-FDG-PET/CT, alone and with correlation to immunohistochemistry biomarkers. 200 consecutive TNBC breast cancer patients treated between 2008 and 2012 were retrieved. Among the full cohort, 79 patients had pre-treatment 18F-FDG-PET/CT scans. Immunostaining status of basal biomarkers (EGFR, CK5/6) and other clinicopathological variables were obtained. Three PET image features were evaluated: maximum uptake values (SUVmax), mean uptake (SUVmean), and metabolic volume (SUVvol) defined by SUV > 2.5. All variables were analyzed versus disease-free survival (DFS) using univariate and multivariate Cox analysis, Kaplan-Meier curves, and log-rank tests. The optimal cutoff points of variables were estimated using time-dependent survival receiver operating characteristic (ROC) analysis. All PET features significantly correlated with proliferation marker Ki-67 (all p < 0.010). SUVmax stratified the prognosis of TNBC patients with optimal cutoff derived by ROC analysis (≤3.5 vs. >3.5, AUC = 0.654, p = 0.006). SUVmax and EGFR were significant prognostic factors in univariate and multivariate Cox analyses. To integrate prognosis of biological and imaging markers, patients were first stratified by EGFR into low (≤15 %) and high (>15 %) risk groups. Further, SUVmax was used as a variable to stratify the two EGFR groups. In the high EGFR group, patients with high FDG uptake (SUVmax > 3.5) had worse survival outcome (median DFS = 7.6 months) than those patients with low FDG uptake (SUVmax ≤ 3.5, median DFS = 11.6 months). In the low EGFR group, high SUVmax also indicated worse survival outcome (17.2 months) than low SUVmax (22.8 months). The risk stratification with integrative EGFR and PET was statistically significant with log-rank p ≪ 0.001. Pre-treatment 18F-FDG-PET/CT imaging has significant prognostic value for predicting survival outcome of TNBC patients. Integrated with basal-biomarker EGFR, PET imaging can further stratify patient risks in the pre-treatment stage and help select appropriate treatment strategies for individual patients.

Abstract 1774: The effects of diarylthiourea analogs on triple negative breast cancer cell growth

Abstract Breast cancer is the most common cancer occurring in women and the second leading cause of cancer death in women after lung cancer. Breast cancer is often classified at the molecular level in terms of whether the cancer expresses the estrogen receptor, progesterone receptor and human epidermal growth factor 2 receptor. Hormone receptor positive breast cancer accounts for 75-80% of all breast cancer and the remaining 20-25% accounts for the most aggressive types of cancer which are negative for all three receptors– known as triple negative breast cancer (TNBC). The current treatment used to manage TNBC is chemotherapy. Although chemotherapy has been effective in improving patients’ prognosis, a significant number of patients either relapse or develop resistance to these drugs. There is a significant interest in developing new therapeutic drugs aimed at improving outcomes in TNBC patients. Many studies have shown that flexible heteroarotinoids (Flex-Het) are a promising new class of drugs due to their ability to regulate growth, differentiation and apoptosis in a variety of cancer cells without activating the nuclear retinoic acid receptors. Previous studies have shown ShetA2 as the leading Flex-Het anti-cancer drug with the greatest efficacy in treating various types of cancer cells (Liu et al. 2004, Benbrook et al. 2005, and Liu et al. 2007). Some of the limitations of the ShetA2 are its high lipophilicity, toxic side effects and the low yields associated with the laborious synthesis. Therefore, efforts have been made to develop 2nd generation diarylthiourea compounds that retain anti-cancer activity, but with minimal side effects. The objective of this study was to examine the effects of two 2nd generation drugs SL1-18 and SL1-09 on various TNBC cell lines including MDA-MB-453, MDA-MB-231 and MDA-MB-468. Our preliminary data shows that exposure to micromolar levels of the diarylthiourea compounds effectively inhibited cancer cell growth in all three TNBC cell lines; however additional studies are necessary to understand the molecular mechanism of how SL1-18 and SL1-09 work to block cell growth and whether these anti-cancer drugs are promising therapeutic leads for the treatment of triple negative breast cancer. Citation Format: Deborah Nambi, Maggie C. Louie, Shengquan Liu. The effects of diarylthiourea analogs on triple negative breast cancer cell growth. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1774. doi:10.1158/1538-7445.AM2015-1774

Abstract 5340: Dual PI3K and Wnt pathway inhibition is a synergistic combination against triple-negative breast cancer

Abstract Introduction: Triple negative breast cancer (TNBC) accounts for 15% of all breast cancer cases in the United States, and despite its lower incidence, contributes to a disproportionately higher rate of morbidity and mortality compared to other breast cancer subtypes. Because these tumors lack expression of the estrogen, progesterone, or HER-2 receptors (“triple negative”), TNBC patients do not respond to targeted therapies that have been successfully used against tumors that over-express these proteins. Thus, there exists a critical need to improve the outcomes of TNBC patients through the implementation of novel targeted agents. Methods: RNA-seq data from 94 TNBCs (from Indiana University and TCGA) and 20 microdissected normal breast tissues (Komen Tissue Bank) were merged and imported into Partek Genomics Suite. The merged transcript RPKMs were transformed, batch effect corrected, and analyzed for differential expression. Statistically significant genes were imported into Ingenuity Pathway Analysis (IPA) to identify therapeutic targets. For cell based studies, we tested a panel of seven TNBC cell lines using BKM120 and LGK974, a WNT pathway inhibitor, individually. To further enhance antitumor efficacy, we then tested these TNBC cell lines using variable dilutions of both drugs in combination with one another. Cell viability was assessed via Celltiter-Fluor. Synergy between the two drugs was calculated using the Chou-Talalay method. Results: Using next-generation RNA sequencing data of TNBCs and microdissected normal breast tissue, Ingenuity Pathway Analysis identified over-expression and hyper-activation of the PI3K/AKT/mTOR and Wnt pathways. When anti-tumor efficacy against these pathways was assessed, a significant reduction in cell viability in combination was observed across the panel of cell lines. Using the Chou-Talalay method, we found for MDA-MB-231 and Hs578T, a ∼50% reduction in cell viability at 100nM concentration of each drug that was highly synergistic (Combination Index = 0.33, and 0.36 respectively). For HCC70, this cell line was more resistant to the combination and we observed ∼50% reduction at 1uM each that had an additive, non-synergistic effect. Conclusion: PI3K/mTOR/AKT and Wnt pathways are a vital target for treatment of TNBC. Using small molecule inhibitors that are in phase trials (BKM120 and LGK974) we have found that there is a strong synergy when given at low nanomolar doses. In vitro studies of inhibitors of these two pathways in a panel of TNBC cell lines demonstrated significant efficacy in reducing cell viability with substantial synergy when used in combination. Furthermore, initial mouse studies display a similar synergy and actual amplification of drug concentration and half-life in the blood of both drugs when given in combination when compared to these two drugs alone. Citation Format: Jeffrey P. Solzak, Rutuja Atale, Brad Hancock, Milan Radovich. Dual PI3K and Wnt pathway inhibition is a synergistic combination against triple-negative breast cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 5340. doi:10.1158/1538-7445.AM2015-5340

S100A14 is a novel independent prognostic biomarker in the triple-negative breast cancer subtype.

Triple-negative breast cancer (TNBC) represents a heterogeneous subgroup with generally poor outcome and lack of an effective targeted therapy. Prognostic or predictive biomarkers to guide treatment decisions for this group of patients are needed. To evaluate the potential of S100A14 protein as a novel biomarker in TNBC, the protein expression of S100A14 was correlated with clinical outcomes in a Pilot Sample set and a Danish cohort of predominantly TNBC patients. Kaplan-Meier analysis identified a prognostic impact of S100A14 on disease-free survival and overall survival, showing that tumors with high S100A14 protein expression levels were significantly correlated with poor outcome in TNBC patients (p = 0.017; p = 0.038), particularly those in the basal-like subgroup (p = 0.006; p = 0.037). Importantly, TNBC patients with high S100A14 expression, but tumor-negative axillary lymph nodes (N-), had equally poor outcomes as those with tumor-positive axillary lymph nodes (N+), while TNBC/N- patients with low S100A14 expression had a significantly better disease free survival (p = 0.013). Multivariate analysis revealed that S100A14 is an independent prognostic factor for TNBC patients (p = 0.024; p = 0.05). At the cellular level, S100A14 was found to be expressed in epithelial-like, but not in mesenchymal-like, TNBC cells in vitro. S100A14 is an independent prognostic factor in TNBC and a novel potential therapeutic target in TNBC.

BCL2 is an independent predictor of outcome in basal-like triple-negative breast cancers treated with adjuvant anthracycline-based chemotherapy.

Neither targeted therapies nor predictors for chemotherapy sensitivity are available for triple-negative breast cancer (TNBC). Our study included 187 patients with TNBC, 164 of whom were treated with anthracycline-based adjuvant chemotherapy. Eleven molecular biomarkers were analyzed. BCL2, epidermal growth factor receptor (EGFR), MYC, TOP2A, and Ki-67 protein expression was evaluated by immunohistochemistry. The status of the EGFR, MYC, and TOP2A genes and chromosomes 7, 8, and 17 was assessed using fluorescence in situ hybridization. High BCL2 expression predicted poor relapse-free survival (RFS) in patients treated with anthracycline-based adjuvant chemotherapy (p = 0.035), poor breast cancer-specific survival (BCSS) (p = 0.048), and a trend to poor overall survival (OS) (p = 0.085). High levels of BCL2 expression predicted poor OS in basal-like (BL) TNBC patients treated with adjuvant anthracycline-based regimens (log-rank p = 0.033, hazard ratio (HR) 3.04, 95 % confidence interval (CI) 1.04-8.91) and a trend to poor RFS (log-rank p = 0.079) and poor BCSS (log-rank p = 0.056). Multivariate analysis showed that BCL2 status, tumor size, and nodal status all had independent predictive significance for RFS (p = 0.005, p = 0.091, p = 0.003, respectively; likelihood ratio test for the whole model, p = 0.003), BCSS (p = 0.012, p = 0.077, p = 0.01, respectively; likelihood ratio test for the whole model, p = 0.016), and OS (p = 0.008, p = 0.004, p = 0.004, respectively; likelihood ratio test for the whole model, p = 0.0006). Similarly, multivariate analysis for BL TNBC showed BCL2, tumor size, and nodal status all had independent predictive significance for RFS (likelihood ratio test for the whole model, p = 0.00125), BCSS (p = 0.00035), and OS (p = 0.00063). High EGFR expression was associated with poor BCSS (p = 0.039) in patients treated with anthracycline-based adjuvant chemotherapy. Patients who underwent anthracycline-based adjuvant chemotherapy and exhibited CMYC amplification had a trend to worse BCSS (p = 0.066). In conclusion, high BCL2 expression is a significant independent predictor of poor outcome in TNBC patients treated with anthracycline-based adjuvant chemotherapy, and this is the first study showing the BCL2 prediction in BL TNBC. BCL2 expression analysis could facilitate decision making on adjuvant treatment in TNBC patients.

Triple negative breast cancer - BCL2 in prognosis and prediction. Review.

Breast cancer (BC), the most frequent malignancy in women worldwide, is currently diagnosed in about 1.4 million female patients annually. Approximately 10-20% of BC is represented by triple negative breast cancer (TNBC) which is aggressive, the prognosis is poor and patients cannot benefit from targeted treatment based on hormonal or HER2 receptors. For this reason, search for markers that can predict the efficacy of chemotherapy in TNBC is a priority. This review focuses on BCL2 protein as a prognostic marker in TNBC and its potential as a predictor of sensitivity to chemotherapy. BCL2 protein expression is a positive prognostic factor in BC. Better survival of patients with BCL2 positivity (BCL2+) has been explained by the correlation with estrogen receptor positive (ER+) status. BCL2+ is however not simply a surrogate marker for ER+. Moreover, BCL2 protein expression is also a positive prognostic marker in the TNBC subgroup. We and others show, that low BCL2 expression was associated with good outcome of TNBC patients treated with both adjuvant and neoadjuvant anthracycline-based chemotherapy. On the other hand, recent studies have shown that a subset of TNBC patients may benefit from the classical adjuvant CMF (cyclophosphamide, methotrexate, 5-fluorouracil) regimen. Given the heterogeneity of TNBC there is an urgent need to find and validate the sensitivity predictors to these regimens making them usable in clinical practice. BCL2 enrichment has been described in the mesenchymal stem-like (MSL) TNBC subgroup.

Pre-operative prognostic nutritional index predicts the outcomes for triple-negative breast cancer

The purpose of this study was to investigate whether pre-operative prognostic nutritional index (PNI), an indicator of nutritional and immunological status, has an impact on the long-term outcomes in triple-negative breast cancer (TNBC) patients. This retrospective study reviewed the medical records of 382 TNBC patients who had suffered from mastectomy. Pre-operative PNI was calculated as 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm(3)). The receiver operating characteristic (ROC) curve analysis was performed to determine the optimal cutoff value of PNI. The correlations of PNI value with clinicopathological features were analyzed and the univariate and multivariate analysis were applied to identify the prognostic factors. The results showed that pre-operative PNI value was significantly related to advanced tumor status such as N stage (p = 0.011), T stage (p = 0.015), and recurrence incidents (p = 0.001). Survival analysis identified PNI as an independent prognostic factor for TNBC. Patients with higher PNI value had better 5-year disease-free survival (DFS) and 5-year overall survival (OS) than those with lower PNI value (DFS, p = 0.007; OS, p = 0.011). Taken together, our results suggest that the pre-operative PNI can be used as a simple and useful marker for predicting the long-term outcomes of TNBC patients.

Outcomes of triple-negative breast cancer (TNBC) versus non-TNBC patients: Does the survival vary for all stages?

e12034 Background: Triple-negative breast cancer (TNBC) poses a therapeutic challenge. In a cohort treated at a tertiary care North Indian center, outcomes of TNBC patients were compared with those...