Feasibility of Measuring the Prognostic Factors uPA and PAI-1 in Core Needle Biopsy Breast Cancer Specimens

JNCI Journal of the National Cancer Institute, Jul 2009

Christoph Thomssen, Nadia Harbeck, Juergen Dittmer, Shanti R. Abraha-Spaeth, Nancy Papendick, Angelo Paradiso, Bjoern Lisboa, Fritz Jaenicke, Manfred Schmitt, Martina Vetter

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Feasibility of Measuring the Prognostic Factors uPA and PAI-1 in Core Needle Biopsy Breast Cancer Specimens

0 The Author 2009. Published by Oxford University Press. All rights reserved. For Permissions , please 1 Department of Gynaecology , Martin-Luther Uni- versity Halle-Wittenberg, Ernst Grube Str 40, 06120 Halle (Saale), Germany ( 2 Affiliations of authors: Department of Gynaecology, Martin-Luther University Halle- Wittenberg , Halle (Saale), Germany (CT , JD, NP, MV); Department of Obstetrics and Gynaecology, University of Cologne , Cologne, Germany (NH ); Department of Gynaecology, University of Hamburg , Hamburg, Germany (SRA-S, BL, FJ); Clinical Experimental Oncology Laboratory, National Cancer Institute , Bari, Italy (AP); Department of Obstetrics and Gynaecology, Technical University Munich , Munich, Germany (MS ) D o w n l o a d e d f r o m h t t p : / / j n c .i o x f o r d j o u r n a .l s o r g / b y g u e s t o n O c t o b e r 2 7 , 2 0 1 4 0 1 2 3 4 5 6 7 8 9 Large tumor specimen: mean uPA (ng/mg protein) Figure 1. Correlation between mean uPA (A) and PAI-1 (B) protein levels in core biopsy specimens and the corresponding large breast cancer tumor tissue specimens (n = 42) as determined by enzyme-linked immunosorbent assay. The dashed lines represent the linear regression curve for all of the samples and the solid gray lines indicate the cutoff values for uPA and PAI-1 (2). - R = .789 P < .001 R = .907 P < .0001 Tumor invasion factors urokinase-type plasminogen activator (uPA) and its inhibitor plasminogen activator inhibitor 1 (PAI-1) are American Society of Clinical Oncology (ASCO)recommended cancer biomarkers for assessing whether nodenegative breast cancer patients can forgo adjuvant chemotherapy (1). Numerous retrospective and prospective analyses (2,3), a multicenter prospective clinical trial (4), and a meta-analysis (5) have demonstrated the strong and statistically independent prognostic and predictive value of uPA and PAI-1 levels in node-negative breast cancer patients at the highest level of evidence. By applying established cutoff values for uPA (3 ng/mg protein) and PAI-1 (14 ng/mg protein) that were determined in primary tumor breast tissue extracts, we showed that uPA and PAI-1 levels distinguish between patients who are at low and high risk of disease recurrence (2). The St Gallen consensus panel 2005 recognized the validity of the uPA and PAI-1 data and suggested the use of uPA and PAI-1 levels as a predictor of endocrine resistance in node-negative breast cancer patients (6). Subsequently, the ASCO Tumor Marker Guidelines 2007 recommended routine clinical use of uPA and PAI-1 for assessing prognosis in patients with newly diagnosed node-negative breast cancer (1). The guidelines recommend the use of approximately 300 mg of fresh or freshfrozen breast cancer tissue for determination of uPA and PAI-1 levels by enzyme-linked immunosorbent assay (ELISA). However, preoperative diagnostic ultrasound-guided core needle biopsy enables early detection of small tumors and provides much smaller tumor samples for the potential use in cancer biomarker determination. We examined the feasibility of measuring uPA and PAI-1 levels in small tissue samples, such as those obtained by needle biopsy, by using a commercially available ELISA test (FEMTELLE; American Diagnostica, Inc., Stamford, CT) to detect uPA and PAI-1 in protein extracts of primary tumor tissue from 42 patients with histologically confirmed invasive breast cancer (7). None of these patients had a preoperative core needle biopsy. Instead, immediately after surgery, we collected three needle biopsy samples (1030 mg each) and three larger tissue pieces (90300 mg each) from each tumor tissue specimen and used them for uPA and PAI-1 determination. The mean uPA and PAI-1 protein levels in the needle biopsy samples correlated statistically significantly with those in the larger tumor specimens (RuPA = .789 and RPAI-1 = .907; P < .001 for each) (Figure 1). By using the published cutoff values for uPA and PAI-1, we found that uPA and PAI-1 levels measured in the needle biopsy specimens correctly classified 40 (95%) of the 42 patients according to their risk of recurrence as determined by the uPA and PAI-1 levels measured in the larger tumor specimens (31 samples were above the cutoffs and nine samples were below the cutoffs); in two cases, the uPA and PAI-1 levels were higher in the needle biopsy samples than in the corresponding larger tumor samples, which resulted in a positive predictive value of 0.94 and a negative predictive value of 1.00. These results clearly demonstrate the feasibility of using a commercially available ELISA test to determine uPA and PAI-1 levels in tissue extracts prepared from needle biopsy specimens. In conclusion, needle biopsy tissue specimens obtained preoperatively can be used for routine uPA and PAI-1 determination in primary breast cancer. However, to account for tumor heterogeneity, two or three biopsy specimens should be assessed. CHRISTOPH THOMSSEN NADIA HARBECK JUERGEN DITTMER SHANTI R. ABRAHA-SPAETH NANCY PAPENDICK ANGELO PARADISO BJOERN LISBOA FRITZ JAENICKE MANFRED SCHMITT MARTINA VETTER inhibitor type 1. J Natl Cancer Inst. 2001; 93(12):913920. 5. Look MP, van Putten WLK, Duffy MJ, et al. Pooled analysis of prognostic impact of urokinase-type plasminogen activator and its inhibitor PAI-1 in 8377 breast cancer patients. J Natl Cancer Inst. 2002;94(2):116128. 6. Goldhirsch A, Glick JH, Gelber RD, et al. Meeting highlights: international expert consensus on the primary therapy of early breast cancer 2005. Ann Oncol. 2005;16(10):15691583. 7. Schmitt M, Sturmheit AS, Welk A, et al. Procedures for the quantitative protein determination of urokinase and its inhibitor, PAI-1, in human breast cancer tissue extracts by ELISA. Methods Mol Med. 2006;120:245265.


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Christoph Thomssen, Nadia Harbeck, Juergen Dittmer, Shanti R. Abraha-Spaeth, Nancy Papendick, Angelo Paradiso, Bjoern Lisboa, Fritz Jaenicke, Manfred Schmitt, Martina Vetter. Feasibility of Measuring the Prognostic Factors uPA and PAI-1 in Core Needle Biopsy Breast Cancer Specimens, JNCI Journal of the National Cancer Institute, 2009, 1028-1029, DOI: 10.1093/jnci/djp145