Immediate Gene Expression Changes After the First Course of Neoadjuvant Chemotherapy in Patients with Primary Breast Cancer Disease
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6418 Vol. 10, 6418–6431, October 1, 2004 Clinical Cancer Research Featured Article Immediate Gene Expression Changes After the First Course of Neoadjuvant Chemotherapy in Patients with Primary Breast Cancer Disease Olga Modlich,1 Hans-Bernd Prisack,1 determined by a different platform was not always satis- Marc Munnes,2 Werner Audretsch,3 and fying. Hans Bojar1 Conclusions: This study has demonstrated the potential 1 of monitoring posttreatment changes in gene expression as a Institute of Chemical Oncology, University of Du¨sseldorf, measure of the pharmacodynamics of drugs. As a clinical Du¨sseldorf; 2Bayer Healthcare AG, Diagnostic Research Germany, Leverkusen; and 3Interdisciplinary Breast Center IBC, City Hospital laboratory model, it can be useful to identify patients with Du¨sseldorf, Du¨sseldorf, Germany sensitive and reactive tumors and to help for optimized choice for sequential therapy and obviously improve relapse- free and overall survival. ABSTRACT Purpose: Our goal was to identify genes undergoing expressional changes shortly after the beginning of neoad- INTRODUCTION juvant chemotherapy for primary breast cancer. Breast cancer, clinically, is a very heterogeneous disease. Experimental Design: The biopsies were taken from The clinical heterogeneity of breast cancers is due to a broad patients with primary breast cancer prior to any treatment diversity of somatic mutations and epigenetic rearrangements and 24 hours after the beginning of the neoadjuvant chem- changing the expression of many genes. Although much effort otherapy. Expression analyses from matched pair samples has been made to develop an optimal clinical treatment course representing 25 patients were carried out with Clontech for an individual patient with breast cancer, only little progress filter arrays. A subcohort of those 25 paired samples were could be achieved predicting the individual’s response to a additionally analyzed with the Affymetrix GeneChip plat- certain therapy. Such predictions are usually based on standard form. All of the transcripts from both platforms were que- clinical conditions such as tumor stage and grade, estrogen ried for expressional changes. receptor (ER) and progesterone receptor (PgR) status, growth Results: Performing hierarchical cluster analysis, we rate, overexpression of the HER2/neu and p53 oncogenes (1). clustered pre- and posttreatment samples from individual However, evidence about association of ER and/or PgR gene patients more closely to each other than the samples taken expression with outcome prediction for adjuvant endocrine from different patients. This reflects the rather low number chemotherapy are still controversial. Studies have shown that of transcripts responding directly to the drugs used. Al- levels of ER and PgR gene expression in breast cancer patients though transcriptional drug response occurring during ther- are of prognostic importance independently from a subsequent apy differed between individual patients, two genes adjuvant chemotherapy (2–4). Oppositely, a newer study has (p21WAF1/CIP1 and MIC-1) were up-regulated in posttreat- demonstrated that PgR status is an independent predictive factor ment samples. This could be validated by semiquantitative that improves outcome prediction for adjuvant endocrine ther- and real-time reverse transcription-PCR. Partial least- apy (5). Moreover, elevated ER and PgR levels are known to be discriminant analysis based on approximately 25 genes in- significantly associated with a progressively better response to dependently identified by either Clontech or Affymetrix tamoxifen and longer survival in ER(ϩ) metastatic breast cancer platforms could clearly discriminate pre- and posttreatment (6). From the theoretical point of view, it is unexpected that the samples. However, correlation of certain gene expression therapeutic response in patients with breast cancer might be levels as well as of differential patterns and clusters as independent from the ER/PgR status. It is more probable that the prognostic impact of receptors’ expression depends on the im- pact of other variables, e.g., the impact of the ERBB2 receptor (7, 8). When conventional biological techniques are used, find- Received 5/26/04; revised 6/24/04; accepted 6/28/04. ing such factors is problematical because all of these techniques The costs of publication of this article were defrayed in part by the survey one gene at a time. payment of page charges. This article must therefore be hereby marked For a few years, DNA microarray technology has been very advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. useful for quantitative measurements of expression levels of Note: Supplementary data for this article can be found at Clinical thousands of genes simultaneously in one sample. Thus far, this Cancer Research Online (http://clincancerres.aacrjournals.org). technology has been used for the classification of cancer tissues, Requests for reprints: Olga Modlich, Institut fu¨r Onkologische Che- e.g., breast tumors (9–24), prediction of metastasis and patient’s mie, Heinrich Heine Universita¨t Du¨sseldorf, Moorenstr. 5, D-40225 Du¨sseldorf, Germany. Phone: 49-211-811-4302; Fax: 49-211-811-5114; outcome (25–38), and tumor response to chemotherapy (39–43). E-mail: [email protected]. It is a well-established fact that adjuvant systematic ©2004 American Association for Cancer Research. treatment after surgery reduces the risk of disease relapse and Downloaded from clincancerres.aacrjournals.org on September 29, 2021. © 2004 American Association for Cancer Research. Clinical Cancer Research 6419 death in patients with primary operable breast cancer (44). As MATERIALS AND METHODS an alternative therapeutic concept, neoadjuvant or primary Patients and Clinical Specimens. From September 1999 systemic therapy (PST) can be offered either to those patients to June 2001, patients with primary breast cancer were enrolled with larger inoperable breast cancers or to patients interested with informed consent for this study with neoadjuvant EC or ET in breast-conserving surgery (45–53). The PST in general do treatment (epirubicin, 90 mg/m2, and cyclophosphamide, 600 mg/ not offer a survival advantage over standard adjuvant treat- m2, or Taxol, 175 mg/m2) as the first therapeutic intervention prior ment, but may identify patients with a pathologically con- to surgery (Table 1). Tumor samples were taken according to firmed complete response (45, 46). This clinical response to institutional review board guidelines. Serial core biopsies of the PST is associated with improved survival (50, 54, 55) and primary tumor were performed before treatment and 24 hours after reflects a great benefit to ϳ14% of the PST-treated patients. the initiation of the first course of the chemotherapy from a locally Studies elaborating PST have demonstrated that early gene anesthetized region with Bard MAGNUM Biopsy Instrument (C.R. expression changes are significantly associated with clinical Bard, Inc., Covington, GA) with Bard Magnum biopsy needles response (56, 57). (BIP GmbH, Tuerkenfeld, Germany). Serial biopsies were taken from a distinct area of the tumor with a 90-degree angle and an In general, all patients of a given cohort do receive the additional skin entry site. This approach was used to avoid the same treatment, even though many will fail in treatment success. detection of gene expression unrelated to treatment, such as tissue Biomarkers reflecting the tumor response can function as sen- injury-related processes. All biopsy samples were snap-frozen in sitive short-term surrogates of long-term outcome. The use of liquid nitrogen and stored at Ϫ80°C until further processing. He- such biomarkers will make chemotherapy more effective for the matoxylin and eosin-stained sections from tumor specimens were individual patient and will allow the changing of regimens early, examined to assess the relative amounts of tumor cells, benign in case of nonresponding tumors as far as the level of evidence epithelium, stroma, and lymphocytes. Standard clinical factors such for biomarker studies is obtained. as ER, PgR, Ki-67, p53, cerbB2/HER2neu have been routinely With this study, we aimed to identify effects of epirubicin/ defined4 in our laboratory. cyclophosphamide (EC) or epirubicin/taxol (ET) treatment on Total RNA Isolation, cDNA Probe Synthesis, and Atlas gene expression in primary breast cancers at 24 hours after the Array Data Analysis. Total RNA from tissue specimens was first treatment. Cyclophosphamide and epirubicin are common extracted according to the protocol recommended for the Atlas therapeutics for advanced and metastatic breast cancer (58). Pure Total RNA labeling system (BD Biosciences Clontech). The Moreover, a therapeutic advantage of epirubicin is the higher amount and quality of RNA were evaluated with UV spectropho- cumulative dose at which the anthracycline-induced cardiotox- tometry (Photometer ECOM 6122, Eppendorf AG, Hamburg, Ger- icity becomes clinically evident in contrast to the more fre- many), agarose gel electrophoresis, and Agilent 2100 Bioanalyzer quently used doxorubicin (Adriamycin). On the other hand, RNA 6000 LabChip kit (Agilent Technologies GmbH, Boeblingen, 32 taxanes have quickly been established as important chemother- Germany) following the manufacturer’s instructions. ␣ P-labeled apeutic agents in the armamentarium of drugs to treat breast cDNA probes were prepared from 5–10 g of total RNA with cancer (59). Expression profiles of