Post on 16-Dec-2015
Prognostic value of occult breast cancer cells
in blood and bone marrow
Gro WiedswangSurgical unit,
Ullevål University Hospital
&The Micrometastasis lab,
Radiumhospital-RikshospitalOslo
Norway
Rome 16.11.06
- why occult tumour cells
- what is occult tumour cells
- occult tumour cells in bone marrow
- timing of bone marrow examination
- occult tumour cells in blood
- clinical trials
- futher perspectives
Challenge of breast cancer
• Better diagnostics• Screening• Improved surgical
treatment• Improved adjuvant
treatment
25-30% of N0 patients die whitin 5 years40% of N1 patients survive > 10 år
Overgaard NEJM 1997
Challenge of breast cancer
• Therapeutic desicions – size of tumour– lymph node involvement– histological grade– hormone receptor– HER-2 status
Improved prognostication!Feature of the patient??
Why micrometastasis?Cancer incidence: > 2500 women/year in
Norway
> 1mill women/ year wordwide
Still 20% 5 year mortality in Norway
Current treatment strategies does not catch patients at risk / overtreat low-risk patients
Micrometastasis / occult tumour cells:
- prognostic tool
- identify high/low risk patients
- monitoring therapy
- identify therapeutic targets
Why micrometastasis ?
Patients do relapse after removing the whole breast and negative lymph nodes
Early, subclinical dissemination of tumour cells
TNM staging does not catch all patients at risk
Isolated tumour cells for prognostication ?
Mikrometastasis• Groups of tumour cells 0.2-2mm in
another tissue than primary tumour (AJCC
2002, UICC 2002) • bone marrow / lymph nodes / blood• signs of invastion and organisation (Diel &
Cote, Ca Treat Reviews 2000)
Occult tumour cells
• disseminated tumour cells• circulating tumour cells• minimal residual disease• micrometastasis• early cancer spread
Pilot studies
Ref.
Salvadori 1990
Mansi 1991
Diel 1994
Harbeck 1994
BM+
17%
25%
45%
38%
Follow-up (mnd)
48
76
77
39
Relapse BM-
24%
25%
23%
15%
Relapse BM+
30%
48%
77%
39%
p-value
ns
<0.005
<0.005
<0.005
•Collaboration between several hospitals in the Oslo region
•aspiration of 40 ml bone marrow from crista iliaca ant and post peroperatively
•920 patients included (1995-98)
Oslo Micrometastasis project
Isolation of mononuclear cells
Immunocytochemical detection
• Single cell suspension2 x 106 cells/test
• Spinns to slides• fixation - acetone
• Anti-epitelial antibodyAE1/AE3
• Enzymatic visualisation of antibody - APAAP
YY
Y
Tumour cell
Standardization of the immunocytochemical detection of cancer cells in BM and blood:
I. Establishment of objective criteria for the evaluation of immunostained cells
The European ISHAGE Working Group for Standardization of Tumor cell detection
E. Borgen et al. 1999. Cytotherapy 1:377-388
Histopatological datan=920
Nodal status
Tumor status
N0
N+
T1
T2
T3-4
63%
33%
58%
29%
6%
frequency
Naume et al Clin Can Res 2001;7:4122-9
Detection of tumour cells
T1 11.2%
T2 15.0%
T3 22.6%
N0 9.9%
N+ 20.6%
Tumour status
Nodal status
BM+
Naume et al Clin Can Res 2001;7:4122-9
Correlation of bone marrow positvity to other known prognostic characteristica
ER/PgR
p53
Catepsin D
c-erbB2
Vascular infiltration
+/-,-/+,+/+-/-
PosNeg
PosNeg
PosNeg
YesNo
12.0 %17.6 %
16.2 %11.9 %
13.1 %14.6 %
23.9 %12.3 %
17.4 %12.6 %
0.055
0.128
0.575
0.024
0.045
BM+ p-value
Naume et al Clin Can Res 2001;7:4122-9
Clinical follow-up
No of patients with infiltrating cancer, M0 and evaluable immunocytology
Obs.time median (range)
No of relapses
No of systemic relapses
No of locoregional relapses
No died of breast cancer
817
49 (½-85) mnd
174 (21%)
127 (16%)
47 (6%)
94 (11%)Wiedswang JCO, 18; 3469, 2003
Localisation of systemic relapse
Wiedswang JCO, 18; 3469, 2003
Frequency %
Skeleton Liver Lung CNS 10.2 5.8 5.2 1.9
Survival according to bone marrow status
p<0.001
DDFS
p<0.001
BCSS
BM- BM-
BM+
BM+
Survival lymph node-pos (N+)
p=0.008p=0.001
DDFS BCSS
BM+
BM+
BM-BM-
Survival lymph node-negative (N0)
BCSSDDFS
Survival T1N0 without adjuvant treatment
BCSS T1N0-adj
TTDØD
100806040200
Cu
m S
urv
iva
l
1,0
,8
,6
,4
,2
0,0
DIICPNEN
2,00
2,00-censored
1,00
1,00-censored
BCSS T1N0-adj
TTDØD
100806040200
Cu
m S
urv
iva
l
1,0
,8
,6
,4
,2
0,0
GR1_2VS3
2,00
2,00-censored
1,00
1,00-censored
p=0.014 P<0.001
Uni -& multivariat analysis
• Cox-regression:– BM+ versus BM- – histological grade – T1 versus T2-4– N0 versus N1– hormone receptor (ER+ or/and PgR+ versus
both-)– p53– c-erbB2– catepsinD– vascular infiltration
Multivariat analysis(Cox regression)
p -values breast cancer specific survival
T-status <0.001 <0.001 nsN-status <0.001BM 0.018 0.015 nshormonreceptor <0.001 <0.001 nshistologic grade 0.002 0.017 0.021
All N+ N0
Multifactorial survial analyses with BM
statusN0 pasienter
Tid til død (mnd)
100806040200
Ove
rle
vels
e
1,0
,8
,6
,4
,2
0,0
multifaktoriell +/-
2,00
2,00-censored
1,00
1,00-censored
N1 pasienter
Tid til død (mnd)
100806040200
Ove
rle
vels
e
1,0
,8
,6
,4
,2
0,0
multifaktoriell +/-
2,00
2,00-censored
1,00
1,00-censored
P<0.001 p=0.003
BM+
BM+
BM-BM-
Mansi et al Patient inclusion: 1981-86
Mansi et al. 1987/91/99
Occult tumour cells in bone marrow and clinical outcome
Braun et al, 2000, NEJM
Persisting tumor cells in BM after chemotherapy - the
impact on survival
Braun et al. 2000
Second bone marrow aspiration 3 years after surgery
Second bone marrow aspiration 3 years after
surgery
• Pasient characteristics (n=356) – 70.2% T1– 71.9% N0– 80.1% hormon receptor positiv
• 14.9% BM+– correlates to nodal status and
adjuvant treatment
Second bone marrow aspiration 3 years after
surgery
• Clinical data: – 26 mnd after BM2– 66 mnd after primary surgery
• 32 relapses – 12 local– 20 systemic
• 10 pasients died of breast cancer
Distant disease free survival
Breast cancer spesific survival
p<0.001 p<0.001Wiedswang et al Clin Ca Res 2004
Survival according to second bone marrow status
Breast cancer specific survival N+
(n=93)
N0(n=256)
p=0.003 p=ns
Wiedswang et al Clin Ca Res 2004
BM1 & BM2
• n= 356 patients• 4 groups:
++ 17 patients+- 54 ” -+ 33 ”-- 231 ”
BM1 & BM2
Distant disease free survival
Breast cancer specific survival
p<0.001 p<0.001
++++
Wiedswang et al Clin Ca Res 2004
”Magasinet”, Dagbladet april 03
Occult tumour cells in blood and bone marrow, correlated to clinical
outcome (n=341)
BM
PB
Months after operation
Cum
ulat
ive
surv
ival
Cum
ulat
ive
surv
ival
p<0.001 p=0.001
BM+
BM-
BM+
BM-
PB+
PB-
PB+
PB-
p=0.002
Events/total no of pts:BM-: 17/293BM+: 10/48
Events/total no of pts:PB-: 20/307PB+: 7/34
Events/total no of pts:PB-: 8/307PB+: 6/34
Events/total no of pts:BM-: 8/293BM+: 6/48
p<0.001
BM+
BM-
PB+
PB-
p<0.001
p=0.001
Events/total no of pts:PB-: 28/307PB+: 9/34
Events/total no of pts:BM-: 23/293BM+: 14/48
DDFS BCSSDFS
Wiedswang et al Int J Ca 2006
Xenidis JCO 2006,24:3756-62
Benoy et alBr J Ca 2006
RT-PCR
BM and blood
147 M0/M+ pts
Bone marrow superior to blood in predicting outcome