| Abstract | Trostruko negativni rak dojke (TNRD) javlja se u oko šestine svih bolesnica s rakom
dojke, najagresivnijeg je ponašanja i najgore prognoze. To je heterogena bolest, sa
specifičnim molekularnim karakteristikama i prirodnom dinamikom ranog recidiva i brze
progresije. U nedostatku valjanog biobiljega, i time bilo kakvog ciljanog liječenja, danas
je okosnica liječenja TNRD kemoterapija, pri čemu se uočava tzv. TNRD paradoks –
bolja kemosenzitivnost i odgovor na terapiju, no lošije preživljenje. Danas se sve više
nade polaže u pronalazak biobiljega koji će biti od prediktivnog i prognostičkog značaja
u TNRD, kao što su to androgeni receptori (AR) i tumor – infiltrirajući limfociti (TIL).
Provedena je retrospektivna kohortna studija na susljednom uzorku od 152 bolesnice
dijagnosticirane i liječene od ranog TNRD u Klinici za tumore, KBC Sestre milosrdnice,
u razdoblju od 1.1.2009. do 31.12.2012. godine. Analizirane su sociodemografske i
kliničkopatološke varijable dostupne iz računalnog zapisa te je učinjena
imunohistokemijska analiza AR te morfološka HE analiza TIL. Granična vrijednost za
pozitivnost AR iznosila je ≥1%, a TIL su analizirani potpuno, stromalni (sTIL) i
intratumorski (iTIL), u centralnom tumoru (CT) i na invazivnoj margini (IM). Izračunate
su korelacije svih navedenih parametara te petogodišnje preživljenje bez bolesti (DFS) i
sveukupno preživljenje (OS). Bolesnice su bile medijana dobi 58 godina, većinom
postmenopauzalne, najčešće stadija II bolesti, gradusa III i medijana Ki-67 57%. Liječene
su operacijski i potom u gotovo 90% slučajeva adjuvantnom kemoterapijom, uglavnom
antraciklinima i taksanima te adjuvantnom radioterapijom. U petogodišnjem praćenju
povrat bolesti bilježi se u trećine bolesnica, najčešće u prvoj godini od dijagnoze,
uglavnom u obliku udaljene diseminacije u pluća i kosti. Petogodišnji DFS iznosi 67.1%, a OS 73.7%. Uz povrat bolesti i smrt najznačajnije su bili povezani čimbenici poput mlađe
dobi, većih tumora, zahvaćenih limfnih čvorova, odnosno višeg stadija bolesti te višeg
proliferacijskog indeksa Ki-67. AR su bili izraženi (≥1%) u 31.1% bolesnica, a u njih
18.5% AR su >50%. Evaluacijom TIL prema navedenim odjeljcima, najgušće zastupljeni
bili su sTIL na IM, s medijanom intenziteta od 30%, i čak 85.5% bolesnica s ≥10%, dok
su najrjeđi i najmanjeg intenziteta bili iTIL u CT, s medijanom intenziteta od 1% i tek
23% bolesnica s ≥10% intenzitetom. Ukupno je četvrtina bolesnica imala TIL>50% u
nekom od evaluiranih odjeljaka. Istovremeno izražene AR (≥1%) i prisutne TIL (>1%)
imalo je 30% bolesnica, a izraženost AR nije bila statistički značajno povezana s
prisutnošću TIL. Izraženost AR nije pokazala statistički značajan utjecaj na preživljenje
bez bolesti, kao niti na ukupno preživljenje. Evaluacija TIL pokazala je statistički
značajan povoljan utjecaj na DFS od sTIL na IM, ali ne i od ostalih odjeljaka. Sveukupno,
pokazalo se da su bolesnice koje su imale TIL≥10% u sva četiri evaluirana odjeljka (sTIL
i iTIL, u CT i na IM) imale statistički značajno bolji DFS, u odnosu na one s TIL<10%.
Stromalni TIL su statistički značajno utjecali na OS, iTIL samo u slučaju ≥10%, sTIL na
IM su bili statistički značajan prediktor boljeg OS, a iTIL na IM samo u slučaju intenziteta
≥10%. AR i TIL u analizi preživljenja pokazali su kako je prisutnost iTIL u CT bila
statistički značajno negativno povezana s petogodišnjim OS u AR+, dok prisutnost
TIL≥10% i AR≥1% nije bila statistički značajan, neovisni prediktor OS. AR su se
pokazali statistički značajno pozitivno povezanima s dobi i menopauzalnim statusom, a
negativno s veličinom tumora, gradusom i Ki-67, kao i stadijem bolesti. Stromalni TIL u
CT bili su statistički značajno povezani s dobi i posljedično menopauzalnim statusom te
veličinom tumora, ali bez povezanosti s drugim varijablama, poput histološkog podtipa,
statusa limfnih čvorova, gradusa i Ki-67; iTIL u CT statistički značajno su pozitivno povezani s histološkim podtipom, odnosno duktalnim karcinomom (NOS), ali i negativno
s dobi i menopauzalnim statusom, upravo suprotno od sTIL u ovom odjeljku, a također
bez povezanosti s drugim karakteristikama tumora, poput veličine tumora, statusa limfnih
čvorova, gradusa ili Ki 67 indeksa; sTIL na IM, kao i iTIL na IM, pokazali su statistički
značajnu povezanost s gradusom tumora i proliferacijskim indeksom Ki-67, a bez
povezanosti s dobi i menopauzalnim statusom. U ovoj analizi AR se nisu pokazali
samostalnim neovisnim čimbenikom prognoze bolesnica s ranim TNRD. TIL su se, kako
je već opisano, pokazali statistički značajnim neovisnim prediktorom prognoze, a rezultat
je, očekivano, najviše na račun stromalnih TIL. Evaluacija TIL po pojedinim odjeljcima
ukazala je na prognostičku vrijednost sTIL na IM. U ovoj analizi se također pokazalo
kako se potencijalna dodatna prognostička vrijednost krije i u interakciji AR s sTIL i iTIL
na IM, iako su rezultati vrlo male preciznosti i pouzdanosti. Naši rezultati preživljenja
bolesnica s ranim TNRD u skladu su sa sličnim analizama na kohortama bolesnica iz
susjednih, ali i udaljenih geografskih oblasti. Kao i u većini analiza, prognostički utjecaj
AR nije se pokazao statistički značajnim. Po prvi put, TIL analizirani su sTIL i iTIL, u
CT i na IM i uočena je vjerojatno različita, prognostički značajna uloga pojedinog
morfološkog odjeljka u tumoru, osobito IM. Svakako najzanimljiviji dio analize bila je
korelacija inače neovisnih parametara, AR i TIL, o čemu se danas tek ponešto zna iz
sporadičnih osvrta o utjecaju imunosti na molekularne podtipove TNRD i u čemu još
nedostaje finalni zaključak, zbog čega i ovom analizom dobiveni zanimljivi preliminarni
rezultati svakako zahtijevaju validaciju u većoj, prospektivnoj studiji. |
| Abstract (english) | Triple-negative breast cancer (TNBC) occurs in about one-sixth of all BC patients, with
the most aggressive behavior and the worst prognosis. It is a heterogeneous disease, with
specific molecular characteristics and natural dynamics of early relapse and rapid
progression. In the absence of a valid biomarker, and thus any targeted treatment,
chemotherapy is nowadays still the backbone of treatment, with the so-called. TNBC
paradox - better chemosensitivity and response to therapy, but worse survival. Today,
more hope lies in finding new biomarkers that will be predictive and prognostic in TNBC,
such as androgen receptors (AR) and tumor-infiltrating lymphocytes (TIL). Retrospective
cohort study was conducted on a consecutive sample of 152 patients diagnosed and
treated for early TNBC at the University Hospital for Tumors, Sestre milosrdnice
University Hospital Center, from Jan 1st 2009 untill Dec 31st 2012. Sociodemographic
and clinicopathological variables available from the hospital record were analyzed and
IHC AR analysis and TIL morphological analysis by HE were performed. Limit for AR
positivity was ≥1%, and TILs were fully analyzed, stromal (sTIL) and intratumoral
(iTIL), in the central tumor (CT) and at the invasive margin (IM). Correlations of all
parameters were calculated as well as 5y DFS and OS. Patients were at median age of 58,
mostly postmenopausal, most commonly stage II disease, grade III, and a median Ki-67
of 57%. They were treated surgically and then in almost 90% of cases with adjuvant
chemotherapy, mainly anthracyclines and taxanes and adjuvant radiotherapy. At 5y
follow-up, disease recurrences are reported in one third of patients, most often in the first
year after diagnosis, mainly in the form of distant metastases to the lungs and bones. The
5y DFS was 67.1% and the OS was 73.7%. Factors such as younger age, larger tumors, involved lymph nodes, or a higher stage of disease, and a higher Ki 67 were most
significantly associated with disease recurrence and death. AR were expressed (≥1%) in
31.1% of patients, and in 18.5% of them AR were> 50%. By evaluating TIL according to
the above mentioned technique, sTIL on IM were most frequently represented, with a
median intensity of 30%, and as many as 85.5% of patients with ≥10%, while the rarest
and of lowest intensity were iTIL in CT, with a median intensity of 1% and 23% of
patients with ≥10%. In total, quarter of patients had TIL>50% in any of the evaluated
compartments. Around 30% of patients had expressed AR (≥1%) and present TIL(>1%)
at the same time, and AR expression was not statistically significantly associated with the
presence of TIL. Expression of AR showed no statistically significant effect on DFS, or
OS. Evaluation of TIL showed a statistically significant favorable effect on DFS of sTIL
on IM, but not of the other compartments. Overall, patients with TIL≥10% in all four
evaluated compartments (sTIL and iTIL, in CT and IM) were shown to have statistically
significantly better DFS, compared to those with TIL<10%. Stromal TIL had statistically
significant effect on OS, iTIL only in the case of ≥10% intensity, sTIL on IM were
statistically significant predictor of better OS, and iTIL on IM only in the case of ≥10%
intensity. AR and TIL in the survival analysis showed that the presence of iTIL in CT
was significantly negatively associated with 5y OS in AR+ tumors, whereas presence of
TIL≥10% and AR≥1% was not statistically significant, independent predictor of OS. AR
were found to be statistically significantly positively correlated with age and menopausal
status, and negatively with tumor size, grade and Ki-67, as well as disease stage. Stromal
TIL in CT were statistically significantly associated with age and consequently
menopausal status and tumor size, but without correlation with other variables, such as
histologic subtype, lymph node status, gradus, and Ki-67; iTIL in CT were statistically significantly positively associated with histologic subtype, ie NOS, but also negatively
with age and menopausal status, exactly opposite to sTIL in this section, and also without
association with other tumor characteristics, such as tumor size, status lymph nodes,
gradients or Ki 67; sTIL on IM, as well as iTIL on IM, showed statistically significant
association with tumor grade and Ki-67, and no association with age and menopausal
status. In this analysis, AR did not prove to be an independent factor in the prognosis of
patients with early TNBC. TIL, as described above, proved to be a statistically significant
independent predictor of prognosis, with the result expected to be mostly at the expense
of stromal TIL. Evaluation of TIL by individual compartments indicated the prognostic
value of sTIL on IM. This analysis also showed that the potential additional prognostic
value lies in the interaction of AR with sTIL and iTIL on IM, although the results are of
very low precision and reliability. Our survival outcomes for patients with early TNBC
are consistent with similar analyzes in cohorts of patients from neighboring as well as
distant geographic areas. As in most analyzes, the prognostic impact of AR did not prove
statistically significant. For the first time, TIL were analyzed with sTIL and iTIL, in CT
and on IM, and a probably different, prognostically significant role of a particular
morphological compartment in the tumor, especially IM, was observed. By far the most
interesting part of the analysis was the correlation of otherwise independent parameters,
AR and TIL, of which little is known today from sporadic reviews on the effect of
immunity on molecular subtypes of TNBC, and which still lacks a definitive conclusion,
which is why also this analysis, providing interesting preliminary results, requires
validation in a larger, prospective study. |
