Bridging Histopathology and Radiomics Toward Prognosis of Metastasis in Early Breast Cancer.

Tumor histomorphology is crucial for the prognostication of breast cancer outcomes because it contains histological, cellular, and molecular tumor heterogeneity related to metastatic potential. To enhance breast cancer prognosis, we aimed to apply radiomics analysis-traditionally used in 3D scans-to 2D histopathology slides. This study tested radiomics analysis in a cohort of 92 breast tumor specimens for outcome prognosis, addressing -omics dimensionality by comparing models with moderate and high feature counts, using least absolute shrinkage and selection operator for feature selection and machine learning for prognostic modeling. In the test folds, models with radiomics features [area under the curves (AUCs) range 0.799-0.823] significantly outperformed the benchmark model, which only included clinicopathological (CP) parameters (AUC = 0.584). The moderate-dimensionality model with 11 CP + 93 radiomics features matched the performance of the highly dimensional models with 1,208 radiomics or 11 CP + 1,208 radiomics features, showing average AUCs of 0.823, 0.799, and 0.807 and accuracies of 79.8, 79.3, and 76.6%, respectively. In conclusion, our application of deep texture radiomics analysis to 2D histopathology showed strong prognostic performance with a moderate-dimensionality model, surpassing a benchmark based on standard CP parameters, indicating that this deep texture histomics approach could potentially become a valuable prognostic tool.

Analysis of Spatial Distribution and Prognostic Value of Different Pan Cytokeratin Immunostaining Intensities in Breast Tumor Tissue Sections.

Cancer risk prognosis could improve patient survival through early personalized treatment decisions. This is the first systematic analysis of the spatial and prognostic distribution of different pan cytokeratin immunostaining intensities in breast tumors. The prognostic model included 102 breast carcinoma patients, with distant metastasis occurrence as the endpoint. We segmented the full intensity range (0-255) of pan cytokeratin digitized immunostaining into seven discrete narrow grey level ranges: 0-130, 130-160, 160-180, 180-200, 200-220, 220-240, and 240-255. These images were subsequently examined by 33 major (GLCM), fractal and first-order statistics computational analysis features. Interestingly, while moderate intensities were strongly associated with metastasis outcome, high intensities of pan cytokeratin immunostaining provided no prognostic value even after an exhaustive computational analysis. The intense pan cytokeratin immunostaining was also relatively rare, suggesting the low differentiation state of epithelial cells. The observed variability in immunostaining intensities highlighted the intratumoral heterogeneity of the malignant cells and its association with a poor disease outcome. The prognostic importance of the moderate intensity range established by complex computational morphology analyses was supported by simple measurements of its immunostaining area which was associated with favorable disease outcome. This study reveals intratumoral heterogeneity of the pan cytokeratin immunostaining together with the prognostic evaluation and spatial distribution of its discrete intensities.

The time-dependent prognostic value of intratumoral cytokine expression profiles in a natural course of primary breast cancer with a long-term follow-up.

Despite the increasing evidence for the importance of immunity in breast cancer, the contradictory role of inflammation has not been thoroughly researched. In this study, we investigate the prognostic value of intratumoral inflammation as evaluated by cytokine mRNA levels. Intratumoral mRNA was measured for IL1ß, IL6, IL8, IL10 and IL17A, using Taqman quantitative PCR. By the AUC criteria, none of the cytokines associated with metastasis outcome over the entire follow-up period. However, separation of the follow-up period has revealed a time-dependent and robust prognostic association of IL ß. It discriminated between patients with and without metastasis relapse by AUCs of 0.21 and 0.82 during the early and late follow-up of 0-7 and 7-14 years, respectively. Interestingly, the prognostic effect by IL1ß shifted during follow-up from good prognosis in the first seven years to bad prognosis thereafter. By the less stringent criteria of Cox regression analysis, other cytokines also significantly associated positively or negatively with metastasis outcome. IL17A associated with good prognosis in the first 7 years of follow up while IL6 associated with poor and IL10 with good prognosis from 7 to 14 years. The revealed time-dependent prognostic effects of cytokine mRNA levels are intriguing and may reflect valuable biological information which should be considered in breast cancer immunotherapy research.

Potential clinical relevance of uPA and PAI-1 levels in node-negative, postmenopausal breast cancer patients bearing histological grade II tumors with ER/PR expression, during an early follow-up.

We evaluated urokinase-type plasminogen activator (uPA) and plasminogen activator inhibitor-1 (PAI-1) prognostic value in postmenopausal, node-negative breast cancer patients bearing tumors with estrogen receptor (ER)/progesterone receptor (PR) expression, treated with locoregional therapy alone, within an early follow-up. We focused our analysis on tumors of histological grade II in order to improve its prognostic value and, consequently, to improve a decision-making process. The cytosol extracts of 73 tumor samples were used for assessing several biomarkers. ER and PR levels were measured by classical biochemical method. Cathepsin D was assayed by a radiometric immunoassay while both uPA and PAI-1 level determinations were performed by enzyme-linked immunosorbent assays. HER-2 gene amplification was determined by chromogenic in situ hybridization (CISH) in primary tumor tissue. Patients bearing tumors smaller than or equal to 2 cm (pT1) or those with low PAI-1 levels (PAI-1 < 6.35 pg/mg) showed favorable outcome compared to patients bearing tumors greater than 2 cm (pT2,3) or those with high PAI-1 levels, respectively. Analyses of 4 phenotypes, defined by tumor size and PAI-1 status, revealed that patients bearing either pT1 tumors, irrespective of PAI-1 levels, or pT2,3 tumors with low PAI-1 levels, had similar disease-free interval probabilities and showed favorable outcome compared to those bearing pT2,3 tumors with high PAI-1 levels. Our findings suggest that tumor size and PAI-1, used in combination as phenotypes are not only prognostic but might also be predictive in node-negative, postmenopausal breast cancer patients bearing histological grade II tumors with ER/PR expression, during an early follow-up period.

Gray-Level Co-Occurrence Matrix Texture Analysis of Breast Tumor Images in Prognosis of Distant Metastasis Risk.

Owing to exceptional heterogeneity in the outcome of invasive breast cancer it is essential to develop highly accurate prognostic tools for effective therapeutic management. Based on this pressing need, we aimed to improve breast cancer prognosis by exploring the prognostic value of tumor histology image analysis. Patient group (n=78) selection was based on invasive breast cancer diagnosis without systemic treatment with a median follow-up of 147 months. Gray-level co-occurrence matrix texture analysis was performed retrospectively on primary tumor tissue section digital images stained either nonspecifically with hematoxylin and eosin or specifically with a pan-cytokeratin antibody cocktail for epithelial malignant cells. Univariate analysis revealed stronger association with metastasis risk by texture analysis when compared with clinicopathological parameters. The combination of individual clinicopathological and texture variables into composite scores resulted in further powerful enhancement of prognostic performance, with an accuracy of up to 90%, discrimination efficiency by the area under the curve [95% confidence interval (CI)] of 0.94 (0.87-0.99) and hazard ratio (95% CI) of 20.1 (7.5-109.4). Internal validation was successfully performed by bootstrap and split-sample cross-validation, suggesting that the models are generalizable. Whereas further validation is needed on an external set of patients, this preliminary study indicates the potential use of primary breast tumor histology texture as a highly accurate, simple, and cost-effective prognostic indicator of distant metastasis risk.

Vascular endothelial growth factor (VEGF) -A, -C and VE-cadherin as potential biomarkers in early breast cancer patients.

BACKGROUND: Vascular endothelial growth factor (VEGF) -A and -C act as multifunctional molecules and growth factors, while VE-cadherin (cadherin 5, CDH5) is the endothelial junction protein. AIM: To assess the relationship between intratumoral VEGF -A, -C and CDH5 levels and clinical outcome, in primary, early-stage, breast cancer patients. PATIENTS AND METHODS: The study included 69 node-negative (N0) breast cancer patients, all of whom had not received any prior hormonal or chemotherapeutic systemic therapy that would affect the course of disease. The median follow-up period was 144 months. Intratumoral mRNA levels of VEGF -A, -C and CDH5 were determined by RT-qPCR. Prognostic performance was evaluated by Cox proportional hazards regression, Kaplan-Meier analysis, as well as by the multivariable approach based on the least absolute shrinkage and selection operator (LASSO) logit regression. Classification of patients into the low and high subgroups was performed using the outcome-oriented cut-off point categorization approach. RESULTS: Of the measured mRNAs, only CDH5 mRNA (t = -2.17; p = 0.04) and VEGF-C mRNA (t = -2.41; p = 0.03) showed significant differences between values in patient subgroups with distant metastasis and those without recurrences, respectively. These t-test results were in agreement with the Cox regression by which CDH5 mRNA reached the most pronounced hazard ratio (HR=2.07; p = 0.05), followed by VEGF-C mRNA (HR=1.59; p = 0.005). HR values above 1.0 indicate that high levels of either CDH5 or VEGF-C mRNAs associated with a higher risk of poor clinical outcome. Distant recurrence incidence was 26% for the CDH5high and 3% for the CDH5low subgroup (Kaplan-Meier analysis). Distant recurrence incidence was 23% for the VEGF-Chigh and 0% for VEGF-Clow subgroup. The independent prognostic value of VEGF-C mRNA was confirmed by LASSO regression. CONCLUSION: Intratumoral VEGF-A levels did not associate with disease outcome in primary, early-stage, breast cancer patients, whilst raised levels of either CDH5 or VEGF-C prognosticated a high risk of distant metastasis.

Can granulysin provide prognostic value in primary breast cancer?

BACKGROUND: Granulysin (GNLY) is a cytolytic and proinflammatory molecule which also acts as an immune alarmin. The multifunctional nature of this molecule has made it challenging to define its full potential as a biomarker in breast cancer. AIM: To evaluate the prognostic value of intratumoral GNLY in primary breast cancer patients and its association with established clinicopathological parameters. PATIENTS AND METHODS: The study included 69 node-negative breast cancer patients with known clinicopathological parameters, all of whom had not received any prior hormonal or chemotherapeutic systemic therapy that would interfere with the course of disease. The median follow-up period was 144 months. Steroid hormone receptor status was determined by ligand-binding assay and HER2 status by chromogenic in situ hybridisation (CISH). Intratumoral GNLY mRNA levels were determined by RT-qPCR. Prognostic performance was evaluated by the receiver operating characteristic (ROC), Cox proportional hazards regression and Kaplan-Meier analysis. Classification of patients into GNLYlow and GNLYhigh subgroups was performed by the use of the outcome-oriented cut-off point categorisation approach. RESULTS: There was a significant difference between GNLY values of patients without any recurrences and those with local or distant recurrences (Mann-Whitney test, p = 0.05 and p = 0.02, respectively). None of the tested parameters showed prognostic significance for local and distant recurrences when combined. When distant metastases and local recurrences were separated as events, the best prognostic performance was observed for GNLY as compared with any clinicopathological parameter (AUC=0.24 and p = 0.04 for local events; AUC=0.71 and p = 0.03 for distant events). Local recurrence incidence was 0% for the GNLYhigh subgroup and 19% for the GNLYlow subgroup; however distant recurrence incidence was 24% for the GNLYhigh subgroup but only 3% for the GNLYlow subgroup (Kaplan-Meier analysis). A significant positive correlation was found between intratumoral ER and GNLY levels, and a significant negative correlation between tumour grade and GNLY levels. CONCLUSION: High levels of granulysin prognosticate low risk of local recurrence but a high risk of distant metastasis in primary, untreated, breast cancer patients.

The prognostic time dependence of intra-tumoural IFNγ mRNA and protein in patients with breast cancer followed for 14 years after surgery and radiotherapy, without subsequent systemic therapy.

There is increasing evidence for the importance of immunity in breast cancer. IFNγ is expected to have a prognostic value based on its major role in innate and specific cell-mediated immunity. In this retrospective study, based on the 14-year follow-up of 73 patients with breast cancer after surgery and radiotherapy but no subsequent systemic therapy, we investigated the prognostic time dependence of intra-tumoural IFNγ mRNA and protein levels. Over the entire 14 years of follow-up, neither IFNγ mRNA nor protein was significantly associated with metastasis outcome by AUC and Cox regression criteria. However, evaluation of the shorter periods has revealed a prognostic significance in the late follow-up period of 7-14 years for IFNγ mRNA and protein with the maximal respective AUCs of 0.72 and 0.73 and hazard ratios of 6.1 and 5.2, respectively. Interestingly, the opposite prognostic association was discovered for IFNγ mRNA and protein in the first 7 years of follow-up, possibly due to the negative correlation of IFNγ protein and mRNA. Moreover, the prognostic association of IFNγ mRNA has shifted from marking the favourable outcome in the first 7 years to poor outcome thereafter. This study contributes to clarification of the previously inconsistent prognostic performance of IFNγ by providing the first prognostic evaluation with long follow-up, time-dependence assessment and absence of any chemotherapy influence.

bFGF in tumor tissue independently prognosticates disease outcome of a natural course of invasive breast cancer.

BACKGROUND: Basic fibroblast growth factor (bFGF) is a potent angiogenic and mitogenic factor that has been functionally predisposed to promote tumorigenesis, while literature data also associate bFGF with a favorable outcome of breast cancer. OBJECTIVE: In order to help resolve such controversy, this study set out to investigate the role of bFGF in breast cancer for the first time by use of the node-negative patient group with smaller tumors and without any systemic adjuvant therapy. This has allowed an increased homogeneity of the group and a far more reliable interpretation of results. METHODS: The study included 133 node-negative breast cancer patients with 33 distant metastasis events. bFGF levels were determined by ELISA in primary tumor tissue homogenates. RESULTS: bFGF in primary tumor tissue associated with favorable breast cancer outcome and its levels significantly and positively correlated with ER levels. CONCLUSIONS: The obtained results are relevant for the future prognostic research aimed at surpassing the currently achievable prognostic accuracies which are by far inadequate to allow reliable therapeutic decision making in breast cancer.

Prognostic biomarker value of binary and grayscale breast tumor histopathology images.

AIM: Breast cancer prognosis is in the spotlight owing to its potentially major clinical importance in effective therapeutic management. Following our recent prognostic establishment of the fractal features calculated on binary breast tumor histopathology images, this study aimed to accomplish the first optimization of this methodology by direct comparison of monofractal, multifractal and co-occurrence algorithms in analysis of binary versus grayscale image formats. PATIENTS & METHODS: The study included 93 patients with invasive breast cancer, without systemic treatment and a long median follow-up of 150 months. RESULTS: Grayscale images provided a better prognostic source in comparison to binary, while monofractal, multifractal and co-occurrence image analysis algorithms exerted a comparable performance. CONCLUSION: The critical prognostic importance of the grayscale texture is revealed.

Markers of progression and invasion in short term follow up of untreated breast cancer patients.

BACKGROUND: Cancer progression and metastasis are complex processes, dependent of molecules involved in inflammation, degradation and invasion. These molecules can be used as prognostic indicators to single out patients with higher risk of recurrence. Interleukin-8 (IL-8) has a role in inflammation, urokinase plasminogen activator (uPA), plasminogen activator inhibitor type-1 (PAI-1) and matrix metalloproteinase-2, -9 have a decisive part in the process of degradation and invasion, while vascular endothelial growth factor (VEGF) is consequential for angiogenesis. OBJECTIVES: Aim of our study is to determine relations between IL-8, uPA, PAI-1, MMP-2, -9, VEGF as their prognostic significance in terms of recurrence free survival. METHODS: This study included 91 untreated patients with lymph node negative (N0) primary breast cancer. RESULTS: Patients with higher levels of uPA (p= 0.05), PAI-1 (0.05), MMP2 (p= 0.05) and IL-8 (p= 0.02) have a poor prognosis. Positive correlations were found between ER - PR, uPA - PAI-1, uPA - MMP9, PAI-1 - IL-8, MMP9 - IL-8, MMP9 - VEGF. Negative correlations were found between ER - IL-8, uPA - IL-8, MMP2 - VEGF. CONCLUSIONS: Higher concentrations of IL-8, uPA, PAI-1 and MMP2, as is MMP9 and VEGF, confirmed aggressive phenotype and poor prognosis in different subgroups.

Selection of clinically useful angiogenesis-related biomarkers: an update.

Angiogenesis is a complex phenomenon that involves interaction between growth factors/cytokines and their receptors, and proteolytic enzymes and their inhibitors, which, in addition to and in accordance with their main roles, act together during this multistep process. Cancer angiogenesis is specific, because the same factors that enable angiogenesis are involved in the process of carcinogenesis. The aim of this review was to analyze the current knowledge regarding the significance of selected biomarkers in cancer angiogenesis, with emphasis on their prognostic value in the circulation.