Download ( mTIL) signatures in HER2-positive breast cancer patients in N9831

Prognostic value of molecular tumor infiltrating lymphocyte
mTIL) signatures
(
in HER2-positive breast
cancer patients in N9831 and
FinHer/FinXX trials.
S. Chumsri1, D.J. Serie2, A. Mashadi-Hossein3, K. Tenner4, S. Lauttia5, A. Moreno-Aspitia1, S.A. McLaughlin1, A. Nassar2, S. Warren3, P. Danaher3, G. Colon-Otero1, H. Lindman5,
H. Joensuu5, E.A. Perez1, E.A. Thompson6.
SABCS 2016
PD5-06 Abst#553
1Jacoby
Center for Breast Health, Mayo Clinic Florida, 2Department of Health and Human Services, Mayo Clinic Florida, 3NanoString, Inc., Seattle WA, 4Department of Health and Human Services, Mayo Clinic Rochester,
5Department of Oncology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland, 6Department of Cancer Biology, Mayo Clinic Florida
Background
mTIL Signature and Outcome in N9831
Adaptive Immune Signatures and Outcome
Trastuzumab is a humanized IgG1 κ monoclonal antibody against extracellular domain of human epidermal growth factor receptor 2
(HER2). While its anti-tumor activities are not fully understood, there are several proposed mechanisms of action. These mechanisms
include inhibition of ligand-independent HER2 dimerization, inhibition of downstream signal transduction, induction of cell cycle
arrest, induction of apoptosis, inhibition of angiogenesis, and DNA repair interference. Besides these described mechanisms, previous
studies demonstrated that engagement of immune effector cells also plays a pivotal role in the anti-tumor effects of trastuzumab.1
The North Central Cancer Treatment Group N9831 (NCCTG-N9831) trial is a randomized, phase III trial that evaluated the benefit of
trastuzumab in the adjuvant setting. In this trial, patients were randomized to receive 3 treatment arms, including arm A treated with
chemotherapy alone (AC-T), arm B treated with chemotherapy followed by sequential trastuzumab (AC-T-H),and arm C treated with
trastuzumab concurrently with chemotherapy (AC-TH). Our previous genomic analysis from the N9831 trial demonstrated that
patients with pre-existing immune gene enrichment of ≥ 9 of 14 immune function genes in their primary tumors had significant
improvement in relapse-free survival (RFS) in the combined analysis of arms B and C. However, enriched immune function gene
expression was not associated with increased RFS in patients receiving chemotherapy alone. 2
Recently, several clinical studies demonstrated prognostic implication of tumor infiltrating lymphocytes (TILs) in breast cancer,
particularly in triple negative and HER2-positive subtypes. In HER2-positive breast cancer, TILs have been associated with improved
outcome in patients treated with chemotherapy.3 In the BIG 02-98 trial, a phase III trial comparing anthracycline-containing regimen vs.
anthracycline and taxane-containing regimen, increasing TILs were associated with a significant improvement in disease-free survival
and overall survival.4 A similar finding was reported in the FinHER trial, a randomized phase III trial of chemotherapy in combination
with 9 weeks of trastuzumab vs. no trastuzumab, with significant improvement in distant disease-free survival with each 10%
increment in TILs in patients treated with an abbreviated course of trastuzumab.5 In the N9831, pre-existing stromal TILs (sTILs) were
associated with a significant improvement in RFS in patients who received chemotherapy only (arm A), but not in the concurrent
trastuzumab arm (arm C).6 However, TILs were not assessed in the sequential arm (arm B).
Nevertheless, scoring of TILs is somewhat subjective and can be operator dependent. Currently, there is no consensus for a clinically
relevant TIL threshold or cutoff.3 In addition, there are two described forms of TILs, namely sTILs and intratumoral TILs (iTILs). The
biological relevance and significance of sTILs vs. iTILs remain rather unclear. Besides these technical challenges, the nature and
subtype of these infiltrating lymphocytes cannot be assessed solely based on morphological appearance. In this study, we sought to
analyze molecular signature of different subsets of tumor infiltrating immune cell populations, using NanoStringTM gene expression
data to assess molecular TIL (mTIL) signature enrichment and different immune subtypes as a function of RFS.
Treatment
mTIL Subset Signatures and Intrinsic Subtypes
N = 293
(Events 88)
Methods
Patients
A total of 1,280 patients from the N9831,7 168 patients in FinHer,8 and 170 patients in FinXX9 were included in this analysis. In N9831,
patients in arm A were treated with chemotherapy alone (AC-T), arm B received chemotherapy followed by sequential trastuzumab
8 patients were randomized to
(AC-T-H), and arm C received trastuzumab concurrently with chemotherapy (AC-TH). In the FinHer trial,
receive either docetaxel or vinorelbine with or without trastuzumab for 9 weeks. In the FinXX 9 trial, patients were randomized to
receive either 3 cycles of docetaxel and capecitabine followed by 3 cycles of cyclophosphamide, epirubicin, and capecitabine (TX/CEX)
or 3 cycles of docetaxel followed by 3 cycles of cyclophosphamide, epirubicin, and fluorouracil (T/CEF). After May 2005, concurrent
administration of trastuzumab was allowed; 96 (13%) and 83 patients (11%) assigned to TX/CEX and T/CEF, respectively, received
trastuzumab for either 9 weeks or up to 1 year. Median follow-up was 10.6 years (range 0.8 months - 15.3 years) in the N9831 trial, 5.5
years in the FinHER trial, and 7.0 years in the FinXX trial.
Immune subset signatures
NanoStringTM technology was used to quantify mRNA in paraffin embedded tumor samples from N9831, FinHER, and FinXX trials.
Immune subset signatures were calculated using normalized and log2 transformed data. The geometric mean across relevant genes
listed in the table below was calculated to generate the composite score for each immune subset signature, namely CD45, B-cells, CD8
T-cells, cytotoxic-cells, and T-cells. The score was mean-centered and standardized in all analyses.
Immune Subset Signatures
CD45
N9831
PTPRC
FinHER/FinXX
N = 98
(Events 21)
N = 296
(Events 69)
•
•
N = 73
(Events 7)
N = 237
(Events 46)
•
•
mTIL Subset Signatures and Outcome in N9831 and FinHER/XX
L95
U95
P
Arm A
0.89
0.75
1.05
0.163
Arm B
0.70
0.56
0.86
0.001
Arm C
0.70
0.55
0.91
0.006
Conclusions
•
N = 94
(Events 30)
HR
Consistent with our previous report on sTILs, pre-existing CD45 mTIL signature was
significantly associated with an improved outcome in the chemotherapy-treated arm, but not in
the concurrent trastuzumab-treated arm. While there was no association between CD45
signature and outcome in the concurrent trastuzumab-treated arm, this signature was
significantly associated with an improved outcome in sequential trastuzumab-treated arm.
Similar to CD45 mTIL signature, cytotoxic and T cell signatures were associated with improved
outcome in chemotherapy and sequential trastuzumab-treated arms, but not in the concurrent
trastuzumab-treated arm.
In contrast to patients with HER2-enriched subtype, none of the mTIL subset signatures were
associated with outcome in patients with luminal subtypes who received chemotherapy. This
observation signifies that the contribution of the immune system to outcome among different
intrinsic subtypes within HER2-positive breast cancer warrants additional investigation.
Our preliminary data suggested that pre-existing adaptive immune enrichment may play a
significant role in determining outcome in HER2-positive breast cancer receiving trastuzumab.
Gene expression analysis allows a more in depth understanding of the role of different immune
subsets compared to histological quantification of TILs. Further studies are needed to validate
the significance of mTIL signatures and adaptive immune signature as predictive or prognostic
biomarkers in HER+ patients.
References
PTPRC
B cells
MS4A1
MS4A1
T cells
CD3D, CD3E, CD3G, TRAT1
CD3D, CD3E, CD3G
CD8 T cells
CD8A
CD8A, FLT3LG
Cytotoxic cells
GNLY, GZMA
CTSW, GNLY, GZMA, PRF1
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2. Perez EA, Thompson EA, Ballman KV, et al: Genomic analysis reveals that immune function genes are strongly linked to clinical outcome in the North Central Cancer Treatment Group n9831 Adjuvant
Trastuzumab Trial. J Clin Oncol 33:701-8, 2015
3. Salgado R, Denkert C, Demaria S, et al: The evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer: recommendations by an International TILs Working Group 2014. Ann Oncol 26:259-71, 2015
4. Loi S, Sirtaine N, Piette F, et al: Prognostic and predictive value of tumor-infiltrating lymphocytes in a phase III randomized adjuvant breast cancer trial in node-positive breast cancer comparing the addition
of docetaxel to doxorubicin with doxorubicin-based chemotherapy: BIG 02-98. JClin Oncol 31:860-7, 2013
5. Loi S, Michiels S, Salgado R, et al: Tumor infiltrating lymphocytes are prognostic in triple negative breast cancer and predictive for trastuzumab benefit in early breast cancer: results from the FinHER trial.
Ann Oncol 25:1544-50, 2014
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Cancer. JAMA oncology 2:56-64, 2016
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B-31 and NCCTG N9831. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 32:3744-52, 2014
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clinical oncology : official journal of the American Society of Clinical Oncology 30:11-8, 2012