Carola Melcher

Circulating tumor cells in breast cancer

Detection of disseminated tumor cells (DTCs) in bone marrow and of circulating tumor cells (CTCs) in the blood has become a major focus of translational cancer research. DTC presence is a common phenomenon seen in 30-40% of primary breast cancer patients and is strongly associated with poor clinical outcome. Since bone marrow biopsy is an invasive procedure, evaluation of CTCs might become a desired alternative. Recent clinical trials have shown CTC detection to be a promising prognostic tool in both primary and metastatic setting. Evaluation of CTCs might be useful for therapy monitoring and their characterization might help to identify novel targets for biological therapies aimed at disrupting earliest steps of metastatic cascade.

The presence and prognostic impact of apoptotic and nonapoptotic disseminated tumor cells in the bone marrow of primary breast cancer patients after neoadjuvant chemotherapy

IntroductionNeoadjuvant systemic therapy of primary breast cancer (PBC) patients offers the possibility to monitor treatment response. However, patients might have metastatic relapse despite achieving a pathologic complete response (pCR). This indicates that local response to therapy must not be representative for systemic treatment efficacy. Therefore, the aim of this study was to compare local response with systemic tumor cell dissemination by determining the presence of disseminated tumor cells (DTCs), including apoptotic tumor cells, in the bone marrow (BM) of PBC patients after neoadjuvant chemotherapy (NACT).MethodsDTCs were detected by immunocytochemistry (pancytokeratin antibody A45-B/B3) and cytomorphology (DTC status). The presence of apoptotic tumor cells was determined by using the M30 antibody (M30 status). This antibody detects a neo-epitope that is expressed only during early apoptosis.ResultsBM aspirates from 400 PBC patients that had completed NACT were eligible for this study. Of these, 167 (42%) patients were DTC positive (DTC status). The M30 status was investigated in 308 patients. Apoptotic (M30-positive) tumor cells were detected in 89 (29%) of these. Whereas the DTC status was not correlated (P = 0.557) to local treatment response (that is, pCR or a clinical complete/partial response), the presence of M30-positive tumor cells was significantly higher in patients that responded to therapy (P = 0.026). Additionally, DTC-positive patients were at an increased risk for disease relapse (hazard ratio, 1.87; 95% CI, 1.11 to 3.15; P = 0.019).ConclusionThe presence of DTC is independent of therapy response of the primary tumor. As patients that are DTC positive after NACT have an unfavorable outcome, they might benefit from additional systemic treatment.

Circulating tumour cells in breast cancer

Evaluation of isolated tumour cells in bone marrow (BM) and peripheral blood has become a major focus of translational cancer research. The presence of disseminated tumour cells in BM is a common phenomenon observed in 30–40% of primary breast cancer patients and independently predicts reduced clinical outcome. The detection of circulating tumour cells (CTCs) in blood might become a desired alternative to the invasive and painful BM biopsy. Recent clinical trials confirmed the feasibility of CTC detection as a robust and reproducible parameter for prognostication in both adjuvant and metastatic setting. The characterisation of CTCs might become an important biomarker for therapy monitoring and help to identify specific targets for novel therapeutic strategies.

Prevalence and prognostic value of disseminated tumor cells in primary endometrial, cervical and vulvar cancer patients

AIMS Disseminated tumor cell (DTC) detection in bone marrow (BM) of primary breast cancer patients predicts poor prognosis. This study investigates the prevalence of DTCs and their prognostic significance in primary gynecologic malignancies. PATIENTS & METHODS DTCs from BM aspirates of 603 patients with endometrial (311), cervical (228) and vulvar cancer (64) were identified by the pancytokeratin antibody A45B/B3. RESULTS DTCs were detected in 18% of BM aspirates (21, 16 and 16% in endometrial, cervical and vulvar cancer, respectively). In cervical cancer, DTCs were associated with International Federation of Gynecology and Obstetrics stage, nodal status and lymphangiosis. There was no association between BM status and prognosis. CONCLUSION Tumor cell dissemination is common in gynecological cancer. In contrast to breast cancer, DTCs that derive from cervical, endometrial or vulvar cancer have less potential to initiate metastatic regrow. The molecular mechanisms underlying this observation warrant further investigation.

Abstract OT1-2-03: The DETECT-study concept: Treatment based on the phenotype of circulating tumor cells in HER2-negative metastatic breast cancer

Background: The prognostic impact of circulating tumor cells (CTC) in metastatic breast cancer (MBC) is well demonstrated. The role of CTCs in predicting specific treatment response and the importance of CTC phenotypes for therapeutic decisions will be investigated within the DETECT-study concept. Trial Design and eligibility criteria: The DETECT studies are prospective, multicenter, open-label clinical trials designed for patients with HER2-negative MBC and evidence of CTCs in the peripheral blood. DETECT III is a two-arm study for patients with HER2-positve CTCs, randomized to physician’s choice therapy (chemotherapy or endocrine treatment) with or without additional HER2-targeted treatment with lapatinib. DETECT IV combines tow single-arm studies aimed at patients with HER2-negative CTCs. Postmenopausal patients with hormone-receptor-positive MBC will be treated with the mTOR-inhibitor everolimus in combination with an endocrine therapy of physician’s choice (everolimus cohort), whereas patients with triple-negative or hormone-receptor-positive MBC and indication to chemotherapy will receive eribulin (eribulin cohort). Specific aims: The primary objective of the trials is to estimate the clinical efficacy of treatments, assessed by the CTC clearance rate for DETECT III and by progression-free survival (PFS) for DETECT IV. Methods: Prevalence of CTCs at various time points as well as the HER2 status of CTCs are assessed using the FDA-approved CellSearch System (Veridex, USA). After immunomagnetic enrichment with an anti-EpCam-antibody, cells were labelled with anti-CK8/18/19 and anti-CD45 antibodies to distinguish epithelial cells from leucocytes. A fluorescein conjugate antibody with anti-CK-Fluorescein Isothiocyanate (FITC) was used for HER2 phenotyping. The cut-off for CTC-positivity was 1 CTC and for HER2 1 CTC with strong HER2-staining (+++). Survival endpoints will be estimated using the Kaplan-Meier method. Present and target accrual: Overall, about 2000 patients with HER2-negative MBC will have to be screened for CTCs to be able to recruit 228 patients with HER2-positive CTCs for DETECT III (which started in February 2012), 400 patients with HER2-negative CTCs for DETECT IV- everolimus cohort (which started in December 2013) and 120 patients for DETECT IV- eribulin cohort (which will start in the second half of 2014). 907 patients have been recruited for CTC screening until June 2014. Perspectives: One screening for CTCs offers different treatment options for patients with HER2-negative MBC and evidence of CTCs within the DETECT-study concept. DETEC III is the first study to investigate a personalized targeted treatment based on the phenotype of CTCs. The addition of a HER2-targeted therapy in case of HER2-positive CTCs is innovative and in case of success will lead to new treatment strategies in MBC. DETECT IV complements DETECT III with regard to additional therapy indications. Citation Format: Bernadette AS Jaeger, Susanne Albrecht, Fabienne Schochter, Carola A Melcher, Carsten Hagenbeck, Thomas WP Friedl, Brigitte Rack, Volkmar Muller, Peter A Fasching, Wolfgang Janni, Tanja Fehm. The DETECT-study concept: Treatment based on the phenotype of circulating tumor cells in HER2-negative metastatic breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr OT1-2-03.

Abstract P4-01-08: Persistence of circulating tumor cells immediately after and two years after systemic adjuvant chemotherapy in patients with early breast cancer – Results of the German SUCCESS trials

Background There is growing evidence that circulating tumor cells (CTCs) have prognostic impact in patients (pts) with early breast cancer (EBC). In this study the persistence of CTCs immediately after and two years after chemotherapy (Ctx) was prospectively evaluated according to molecular subtypes within the German multicentre SUCCESS trials. Methods SUCCESS A and C were randomized Phase III studies including pts with node positive or high-risk node negative EBC. In each trial two different adjuvant Ctx regimen were compared: FEC-DOC (3 cycles of FEC followed by 3 cycles of Docetaxel) to FEC-DG (3 cycles of FEC followed by 3 cycles of Docetaxel/Gemcitabine) in SUCCESS A and in the SUCCESS C study FEC-DOC to an anthracycline-free Ctx regimen (6 cycles of Docetaxel/Cyclophosphamide). Both studies involved a second randomization after Ctx: 2 vs. 5 years of zoledronic acid treatment (SUCCESS A) or 2-years of an individualized lifestyle-intervention program vs. general lifestyle recommendations (SUCCESS C). Adequate endocrine treatment and treatment with trastuzumab as indicated were included in both trials. As part of the translational research program, 23ml of peripheral blood were drawn to isolate CTCs using the CellSearch System (Veridex, USA). After immunomagnetic enrichment with an anti-EpCam-antibody, cells were labelled with anti-CK8/18/19 and anti-CD45 antibodies to distinguish epithelial cells from leucocytes. The cut-off for CTC-positivity was ≥ 1 CTC. Molecular subtypes were defined as luminal-A-like (hormone-receptor positive, G1 or 2), luminal-B-like (hormone-receptor positive, G3), HER2-positive and triple-negative. Results CTC analyses were performed for 3344 blood samples collected immediately after Ctx and for 1352 blood samples two years after Ctx. After Ctx 17.5% (584/3344) of the pts were CTC-positive (range 1 – 124 CTCs), and two years after Ctx the positivity rate for CTCs was 17.2% (233/1352, range 1-99). CTC positivity as assessed immediately after Ctx differed significantly among molecular subtypes (chi-square test, p Two years after Ctx CTC-positivity did not differ significantly among molecular subtypes (chi-square test, p = 0.463). CTC-positivity rates were 15.7% (96/613) for luminal-A-like tumors, 19.1% (49/256) for luminal-B-like tumors, 17.2% (51/296) for HER2-positive tumors, and 19.8% (37/187) for triple-negative tumors. Conclusions The data of this study confirm previous findings that CTCs may persist after standard adjuvant therapy. Immediately after Ctx CTCs seem to be more frequent in pts with HER2-positive tumors as compared to other molecular subtypes, while two years after Ctx no differences in CTC positivity among molecular subtypes were detected. These results might indicate good efficacy of HER2-targeted therapies on CTCs. Citation Format: Bernadette AS Jaeger, Ulrich Andergassen, Julia K Neugebauer, Marianna Alunni-Fabbroni, Carola A Melcher, Carsten Hagenbeck, Susanne Albrecht, Ralf Lorenz, Thomas Decker, Georg Heinrich, Tanja Fehm, Andreas Schneeweiss, Matthias W Beckmann, Klaus Pantel, Klaus Friese, Peter A Fasching, Thomas WP Friedl, Wolfgang Janni, Brigitte K Rack. Persistence of circulating tumor cells immediately after and two years after systemic adjuvant chemotherapy in patients with early breast cancer – Results of the German SUCCESS trials [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P4-01-08.