History of proposed TNBC classification systems.
Abstract
Triple-negative breast cancer (TNBC) is defined as a molecular subtype of breast cancer that lacks expression of hormone receptors (oestrogen and progesterone receptor) and HER2/neu/ErbB2 protein. It accounts for 15–20% of all invasive breast cancers. The occurrence of TNBC is often associated with younger age at the time of diagnosis and pre-menopausal status, early onset of menarche, higher body mass index (BMI) in the pre-menopausal period, race and ethnicity (African, Hispanic) and the presence of germline mutation in the BRCA1/2 genes or somatic mutation in the TP53 or PTEN genes. TNBCs are specific in its aggressive biological behaviour, shorter interval to disease progression and more frequent relapse within five years (19 to 40 months). The most of TNBCs are represented by high-grade invasive carcinomas of no special type (NST) with high proliferation index measured by Ki-67 nuclear expression, followed by metaplastic carcinomas, secretory carcinomas, and adenoid cystic carcinomas. Genetical and morphological heterogeneity inside TNBC is responsible for the higher frequency of primary and secondary resistance to systemic therapy. The scope of this chapter is to summarise the potential therapeutic agents involved in regulation of cell proliferation, migration, angiogenesis, apoptosis, gene expression and DNA damage or immune response. The insight into this issue is essential for the setting of the optimal chemotherapy regimen and targeted therapeutic strategy.
Keywords
- Triple-negative breast cancer
- prognosis
- prediction
- molecular target
1. Introduction
Triple - negative breast cancer (TNBC) represents a morphologically and genetically heterogeneous molecular subtype of breast cancer lacking the expression of hormone receptors (oestrogen and progesterone receptor) and HER2/neu/ErbB2 protein. It accounts for 15–20% of all cases [1]. The occurrence of TNBC is often associated with younger age at the time of diagnosis and pre-menopausal status, early onset of menarche, higher body mass index (BMI) in the pre-menopausal period, race and ethnicity (African, Hispanic) and the presence of germline mutation in the
From a clinical point of view, TNBC is specific in its aggressive biological behaviour, shorter interval to disease progression and more frequent relapse within five years (19 to 40 months vs. 35 to 65 months) [4]. The median overall survival (OS) for metastatic TNBC is reported to be 9 to 12 months [5]. Due to these tumour characteristics, chemotherapy is often indicated already during the initial phase of treatment. Heterogeneity inside TNBC is responsible for the higher frequency of primary and secondary resistance to treatment [6]. The current research trends therefore focus on finding the new potentially therapeutically manageable molecules, which could significantly help to decrease the risk of metastasis development and disease recurrence.
Compared to other molecular subtypes, TNBCs differ in their high degree of gene instability. Based on the gene expression profiling, TNBC can be subclassified into several distinct molecular subtypes. Lehmann et al. represent one of the first research groups using this approach in practical diagnostics [7, 8]. Since then, a couple of classification schemes have been introduced; see Table 1 [9, 10, 11, 12, 13].
Authors | TNBC subtype | Basic molecular characteristics |
---|---|---|
Ma et al. [9] | BL | Increased CK5/6, EGFR expression |
LAR | Increased AR expression | |
“Claudin - low” | CD44+/CD24- immunophenotype | |
Decreased claudin 3, 4, 7 expression | ||
Lehmann et al. [7] | BL1 | Increased Ki-67 expression |
BL2 | Increased CD10, p63 expression | |
LAR | Increased AR expression | |
Aberrant | ||
M | Aberrant regulation of Wnt, ALK, TGF-β | |
MSL | Aberrant regulation of Rho, ALK, TGF-β, Wnt/β-catenin, ERK1/2, EGFR, PDGF, PI3K | |
IM | Aberrant regulation of NFKB, TNF, JAK/STAT | |
Burstein et al. [10] | LAR | Increased AR, MUC1 expression |
Aberrant | ||
M | Increased PDGF-A, c-Kit expression | |
BLIA | Aberrant regulation of STAT | |
Presence of B /T/NK immune cells | ||
BLIS | Aberrant regulation of VTCN1 | |
Jézéquel et al. [11] | BL | Immune cells -, TAM – like cells + |
LAR | Increased AR expression Aberrant | |
“BL - enriched” | Immune cells +, TAM – like cells - | |
Ahn et al. [12] | BL | Aberrant |
M | ||
Aberrant regulation of PI3K / AKT | ||
IM | Aberrant regulation of NFKB, TNF, JAK/STAT, VTCN1, presence of B/T/NK immune cells | |
LAR | Increased AR expression Aberrant | |
Zeng et al. [13] | BL | Increased CK5/6, EGFR expression |
NBL | Absence of CK5/6, EGFR expression |
The essential clue for effective breast cancer management is comprehensive evaluation of number of prognostic and predictive molecular indicators. While prognostic factors correlate with patient survival, predictive factors provide information on the response to a specific therapy. The all prognostic clinicopathological characteristics such as patient age at the time of diagnosis, clinical and pathological tumour stage, tumour type with detailed tumour morphology analysis including the intensity of tumour infiltrating lymphocytes (TILs), tumour grade, occurrence and extent of in situ carcinoma and family history of breast cancer should be taken into account.
The most of TNBCs are represented by high-grade invasive carcinomas of no special type (NST) with high proliferation index measured by Ki-67 nuclear expression, followed by metaplastic carcinomas, secretory carcinomas, and adenoid cystic carcinomas [14]. The morphological pattern of invasive carcinomas NST may involve medullary, lipid-rich, apocrine, pleomorphic or spindle cell areas. Carcinomas with spindle tumour cell transformation are usually related to “claudin-low” molecular subtype (CD44+/ D24−/low) and epithelial to mesenchymal transition (EMT) process [15, 16, 17]. Metaplastic breast cancers and secretory carcinomas account for 0.2 to 5%, respectively 0.02% of all breast cancers [14]. Adenoid-cystic carcinomas with typical fusion of the
2. Molecular prognostic and predictive markers
Individual molecules involved in the process of TNBC carcinogenesis may be divided into several groups. The groups of proteins include proteins participating in mechanisms of repair of damaged DNA; proteins responsible for regulation of cell proliferation, migration, angiogenesis, programmed – cell death (apoptosis) and immune response (immune checkpoint proteins; and groups of proteins modifying gene expression (see Table 2).
Regulators in the DNA damage response | BRCA1, BRCA2, PARP, PTEN, pRb, p53 |
Regulators of cell migration and proliferation | EGFR, VEGFR, FGFR |
Regulators of apoptosis | Fas, TRAIL, p53, Bcl-2 |
Regulators of gene expression | microRNA, lncRNA, circRNA, siRNA |
Steroid receptors | Androgen receptor |
Immune checkpoint proteins | PD - 1, PD - L1 |
2.1 Regulators in the DNA damage response
Genes and proteins involved in the repair of damaged DNA (poly (ADP-ribose) polymerase, genes with tumour suppressor function
The enzyme family
Protein Rb (pRb), a product of
2.2 Regulators of cell proliferation, migration and angiogenesis
The loss of effective mechanisms to repair damaged DNA during the cell cycle leads to uncontrolled cell division and their tumour transformation. Adequate nutrition for the tumour cells is provided by the process of angiogenesis. To initiate the metastatic cascade, there must be an increased expression of proteases by tumour cells with subsequent degradation of the basal membrane. Cells of the tumour stroma may amplify the aggressive potential of the tumour even further and thus participate in the EMT process.
2.3 Proteins regulating apoptosis
Cell death receptors Fas and TRAIL of the tumour necrotizing factor (TNF) family are considered to be potential anti-tumour molecules. The
2.4 Regulation of gene expression
Detection of epigenetic changes taking place in breast cancer may aid in determining disease prognosis and in predicting the response to treatment. These primarily include changes in DNA methylation, modification of histones and altering miRNA expression [46, 47, 48, 49, 50, 51, 52, 53]. Recently, the regulatory role of lncRNA, circRNA and siRNA has been described.
The miRNA biosynthesis is predominantly enabled by two major pathways - canonical and non-canonical pathway. The first pathway is initiated by the generation of the pri-miRNA transcript which is cleaved by microprocessor complex (Drosha and DGCR8) into precursor-miRNA (pre-miRNA). Pre-miRNA is transferred by the Exportin5/RanGTP to the cytoplasm and processed by the RNase III endonuclease Dicer to produce the mature miRNA duplex. The load of 5p or 3p strands of the mature miRNA duplex into the Argonaute (AGO) family of proteins to form a miRNA-induced silencing complex (miRISC). The second pathway begins by microprocessor complex – mediated cleavage of small hairpin RNA (shRNA) with following its export to the cytoplasm via Exportin5/RanGTP. Nevertheless, the further possible pathways were identified (e.g. Dicer-independent cleavage, miirtrons and 7-methylguanine capped (m7G)-pre-miRNA formation).
2.5 Steroid androgen receptor
The androgen receptor (AR) is a nuclear steroid hormone receptor which is expressed in 70–90% of all breast cancers [54, 55, 56]. It contains a transactivation N-terminal domain, a DNA-binding domain and a C-terminal domain. The function of AR as a transcription factor is to modulate the activity of steroid-regulated genes, or to alter post-transcription processes, which leads to changes in levels of specific mRNA and proteins. Inactive form of AR is kept in the cytoplasm by a heterocomplex with heat-shock proteins and a chaperone complex (HSP-70, HSP-90). There exist two mechanisms of AR activation – genomic modality and non-genomic modality. Genomic modality is implemented by androgen binding to the C-terminal domain of AR, its conformational change, dimerization and translocation into the nucleus, leading to a promotion of a co-activator-mediated transcription of target genes. Non – genomic modality activates AR through ERK dependent (interaction with PI3K, Src proteins, Ras GTPase) or ERK independent signal transduction (mTOR phosphorylation, FOXO1 inactivation, PKA activation)
In TNBC, increased expression of AR was observed in 10–50% of cases. Although several studies concerning ER-related breast cancers confirm a positive correlation between its increased expression and disease-free survival (DFS) as well as overall survival (OS), others claim the opposite. Expression of AR in TNBC is associated with lower grade, lower proliferation activity and lower disease stage. The lack of AR expression is thus considered to be a factor associated with a higher risk of disease recurrence and development of distant tumour metastases. Taking into account the sensitivity of the tumour to systemic therapy, the use of AR antagonists in clinical practice seems more than promising.
2.6 Immune checkpoint proteins
Physiologically, healthy tissue is protected from damage by its own immunocompetent cells by inducing immune tolerance. It is mediated by cells of the immune system (especially T – lymphocytes, B - lymphocytes, macrophages, dendritic cells), which are able to effectively detect tumour antigens and activate a cellular and humoral antitumour response. A more intense antitumour immune response correlates with longer overall patient survival, period without development of metastases, period without disease relapse and symptom-free interval.
Understanding the mechanism of how tumour cells escape from immune supervision (theory of immunosurveillance) led to the identification of immune checkpoint proteins as potential aims of immunotherapy. The signalling pathway PD1/PD-L1 under normal conditions inhibits the PI3K/Akt and MAP-kinase pathway (Ras/MEK/Er) and leads to the induction of apoptosis and termination of the cell cycle. It also limits the effector function of CD8+ T-lymphocytes in favour of regulatory CD4+ T-lymphocytes. Receptor protein PD-1 is encoded by the gene
The testing of monoclonal antibodies with anti-PD-L1 inhibitory effect and their introduction into clinical practice signified a breakthrough in the treatment of a number of tumours [57, 58, 59, 60, 61, 62, 63, 64, 65]. Increased expression of PD-L1 in tumour cells is generally associated with poor disease prognosis. Contrarily, its increased expression by immune system cells (TILs) prolongs overall patient survival. Increased expression was observed in 20% of TNBC cases. Expression of PD – L1 in the tumour and its metastases in the lymph nodes is very heterogeneous and changes in time. Administration of immune checkpoint inhibitors (anti – PD1 - pembrolizumab, anti – PD-L1 - atezolizumab) with cytotoxic drugs is recommended in advanced forms of TNBC. Atezolizumab in combination with nab – paclitaxel has been shown to be effective; cases with increased expression of PD-L1 reported a prolongation of progression-free survival (PFS) from 5 months to 7.5 months and overall survival (OS) from 15.5 months to 25 months. Complete pathological response (pCR) was reached in 51.9% of cases receiving atezolizumab with nab – paclitaxel and carboplatin, and in 64.8% of cases receiving pembrolizumab with nab – paclitaxel and carboplatin (Figure 3).
3. Conclusions and future perspectives
The issue of TNBC is still a challenge for many investigators over the world. The current scientific interest is mainly focused on the development of promising therapeutic targets. Due to poor prognosis associated with tumour aggressive biological behaviour, high rates of metastases and unpredictable response to the primary systemic chemotherapy and radiotherapy, the detailed analysis of the mechanisms of TNBC genesis is asked. Identification of new potential targets and the development of specific targeted therapy is pivotal for improvement of the existing clinical outcomes. The knowledge of the crucial participation of immune system in carcinogenesis significantly extended the range of therapeutic options. Ongoing clinical trials testing different types of molecules may pave the way for effective pharmacological synergy and better treatment results.
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