Circulating Tumor Cells and Their Prognostic and Predictive Value

in Breast CancerMassimo Cristofanilli, M.D., F.A.C.P.

Professor and Chairman Medical Oncology

G. Morris Dorrance Jr. Endowed Chair in Medical Oncology

VIII Simposio Internacional GEICAM A Coruña 31/03-01/04 2011

Introduction

• Prognostic and predictive value of CTCs

enumeration (CellSearch®) in MBC

• Clinical utility of CTCs monitoring

• Molecular characterization of CTCs and CTCs

targeted therapies

CellSearch Technology

A novel concept in oncology or simply another marker?

CellSearch Technology

CellTracks® Technology Standardized Enumeration of

CTC

Allard, W. J. et al. Clin Cancer Res 2004;10:6897-6904

Circulating Tumor Cells (CTCs) in Advanced Epithelial Malignancies

CTCs in MBC

Prognostic Value of Baseline CTC Counts

Progression-Free Survival

Cristofanilli M, et al. N Engl J Med 2004;351:781-791.

% P

rob

ability o

f Pro

gressio

n-F

ree Su

rvival

Time from Baseline (Months)0 2 4 6 8 10 12 14 16 18 22 24 26 28 30

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

20

log rankP =.0001

7.0 Months2.7

Months

> 5 CTCs/7.5 mLn = 87 (49%)

< 5 CTCs/7.5 mLn = 90 (51%)

Prognostic Value of Baseline CTC Counts

Overall Survival

Cristofanilli M, et al. N Engl J Med 2004;351:781-791.

% P

rob

ab

ility o

f Su

rviv

al

Time from Baseline (Months)0 2 4 6 8 10 12 14 16 18 22 24 26 28 30

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

20

log rank P < .000121.9 Months

10.9Months

> 5 CTCs/7.5 mLn = 87 (49%)

< 5 CTCs/7.5 mLn = 90 (51%)

CTCs and outcome during the Course of Therapy

Progression Free Survival Overall Survival

%P

rob

abil

ity

of

Pro

gre

ssio

n F

ree

Su

rviv

al

Time from Blood Draw (Months)0 2 4 6 8 10 12 14 16 18 22 24 26 28 30

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

20

<5 CTCs at: Baseline (n= 90) 3- 5 Weeks (n= 89) 6- 8 Weeks (n= 73) 9-14 Weeks (n= 91)15-20 Weeks (n= 64)

>5 CTCs at: Baseline (n= 87) 3- 5 Weeks (n= 37) 6- 8 Weeks (n= 15) 9-14 Weeks (n= 11)15-20 Weeks (n= 11)

%P

rob

abil

ity

of

Su

rviv

al

Time from Blood Draw (Months)0 2 4 6 8 10 12 14 16 18 22 24 26 28 30

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

20

<5 CTCs at: Baseline (n= 90) 3- 5 Weeks (n= 91) 6- 8 Weeks (n= 77) 9-14 Weeks (n=105)15-20 Weeks (n= 70)

>5 CTCs at: Baseline (n= 87) 3- 5 Weeks (n= 41) 6- 8 Weeks (n= 22) 9-14 Weeks (n= 24)15-20 Weeks (n= 14)

Hayes, DF, Clin Cancer Res. 2006,12:4218-24.

CTCs, Imaging and Prognosis

Budd, G. T. et al. Clin Cancer Res 2006;12:6403-6409

CTCs Functional Imaging And Prognosis

De Giorgi et al , J Clin Oncol, 2009

B

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0%

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40

Pro

ba

bil

ity

of

Ov

era

ll S

urv

iva

l

Time from Midtherapy Draw in Months

Curve Logrank

Comparison p-Value*

1 vs. 2

1 vs. 3

1 vs. 4

2 vs. 3

2 vs. 4

3 vs. 4

0.0018

<0.0001

<0.0001

0.1073

0.2244

0.6441

Midtherapy Median OS in

1 <5 CR/PR/SD 59 (58%) ----- (25.6 to ------)2 <5 PD 22 (21%) 14.7 (7.3 to -------) 3 >5 CR/PR/SD 4 (4%) 4.9 (1.5 to -------)4 >5 PD 17 (17%) 9.8 (5.3 to -------)

Group CTC FDG-PET/CT N (%) Months (95% C.I.)

*p-values not adjusted for

multiple hypothesis

tests

1

2

3

4

Validation Prognostic Value Baseline CTCsin newly diagnosed MBC

Dawood S et Cancer, 113(9):2422-30, 2008

CTCs and metastatic disease sites

Circulating tumor cell (CTC) count relationship with bone metastases.

De Giorgi U et al. Ann Oncol 2009;21:33-39©

Ability of Site(s) of Metastasis to Predict Overall Survival in 195 Metastatic Breast Cancer Patients

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40

12

3

Curve LogrankComparison p-Value* 1 vs. 2 0.7803 1 vs. 3 0.0021 2 vs. 3 0.0164

*p-values not adjusted formultiple hypothesis tests

Site(s) of Median OS in Group Metastasis N (%) Months (95% C.I.) 1 Bone Only 58 (30%) ------ (23.5 to ------) 2 No Bone Involvement 29 (15%) ------ (19.2 to ------) 3 Bone & Other Sites 108 (55%) 18.5 (13.6 to 29.3)

Time from Baseline Blood Draw in Months

Pro

bab

ility

of

Ov

era

ll S

urv

iva

l

Circulating tumor cells as predictor of metastatic disease spread in patients with

breast cancer M. Giuliano1,2¥, A. Giordano1,2, B.C. Handy1, N. T. Ueno1, E. Andreopoulou1, R.H.

Alvarez1, J.M. Reuben1, V. Valero1, G.N. Hortobagyi1, M. Cristofanilli3

1. M.D. Anderson Cancer Center, Houston, TX, US. 2. University of Naples Federico II, Italy. 3. Fox

Chase Cancer Center, Philadelphia, PA, US.

¥ Currently at Baylor College of Medicine, Houston, TX, US.

To demonstrate correlations between CTC detection, metastatic site development and and prognosis. We hypothesized that baseline detection of ≥ 5 CTCs before starting systemic treatment could predict the development of new metastatic sites, when progression of disease occurs.

Study Aims

GroupOverall

N (%)

CTCs < 5 CTCs ≥ 5

PProgression

in pre-existing site(s)

N (%)

Development of new metastatic

site(s)

N (%)

Progression in pre-

existing site(s)

N (%)

Development of new

metastatic site(s)

N (%)

Overall population408

(100)191 (78.3) 53 (21.7) 112 (68.3) 52 (31.7) .028

Bone metastases without visceral involvement

93 (22.8) 35 (76.1) 11 (23.9) 26 (55.3) 21 (44.7) .049

Bone with or without visceral metastases

280 (68.6)

113 (79.6) 29 (20.4) 94 (68.1) 44 (31.9) .03

No bone involvement

128 (31.4)

78 (76.5) 24 (24.5) 18 (69.2) 8 (30.8) .455

Only visceral metastases

84 (20.6) 53 (79.1) 14 (20.9) 11 (64.7) 6 (35.3) .219

Rates of development of new metastatic sites according to baseline CTC value, with stratification based on original site of disease

Lymph nodes/soft tissuesBoneVisceral organs

CTCs < 5 N= 53

CTCs ≥ 5 n= 52

Paerson Chi-Square P= .047

Organ distribution of new metastases in patients who developed new metastatic sites (n= 105), stratified by baseline CTC value.Patients with CTCs ≥ 5 developed significantly more metastases in visceral organs, with less metastases in other organs (lymph nodes/soft tissues, bone) compared to those with CTCs < 5. Fifteen patients out of 52 (28.8%) with CTCs ≥ 5 developed new brain metastases, compared with 7 out of 53 (13.2%) with CTCs < 5 (Fisher’s Exact test P= .058).

%

CTCs < 5

n= 191

CTCs ≥ 5 n= 112

CTCs < 5 n= 69

CTCs ≥ 5 n= 35

P= .001

A. Type of disease progression in the original metastatic sites (increase in size vs new lesion) in patients who did not develop new metastatic sites (n= 303). B. Rates of development of new metastatic lesions (either in pre-existing sites or at new sites) in patients with oligometastatic disease (pre-existing metastases limited to a single organ) n= 104.

ADimensional increase of pre-existing lesion(s) alone

Development of new metastatic lesion(s)B

P= .031

CTCs, molecular subtypes and therapies and metastatic disease

sites

HR+/HER2- (N= 290) HR+/HER2+ (N= 49)

Triple Negative (N= 124)HR-/HER2+ (N= 51)

≥ 5 CTCs (n=128)~ 20.5 months

< 5 CTCs (n=162)~ 34 months

< 5 CTCs (n=33)~ 19.7 months

≥ 5 CTCs (n=18)~ 23 months

< 5 CTCs (n=82)~ 17.8 months

≥ 5 CTCs (n=42)~ 11.1 months

< 5 CTCs (n=32)N/A

≥ 5 CTCs (N=17)N/A

Log Rank P < .001* Log Rank P = .064

Log Rank P = .899 Log Rank P = .01*

PFSHER2+ Patients (N=40) receiving

anti-HER2 treatment*

17

28

13

12

1

1

0

5

10

15

20

25

30

35

≥5

<5

Log Rank P = .839

< 5 CTCs (n=26)~ 15.9 months

≥ 5 CTCs (n=14)~ 16.1 months

CTCs in HER2+ Patients (N=29) before and after 1ST line

anti-HER2 treatment

HER2 positive Patients (chemo-naïve)

* Trastuzumab/Lapatinib

Cox Regression Analysis

CovariatesHazard Ratio

(95% CI)P

CTCs ≥5 vs <5 1.978

(1.471-2.660)<0.001*

ER Positive vs Negative.485

(.328-.717)<0.001*

PR Positive vs Negative.944

(.632-1.411)0.78

Her2/neu Positive vs Negative.610

(.420-.885)0.009*

Visceral Metastasis vs Other1.751

(1.183-2.592)0.005*

# Metastatic Sites (1 vs 2 vs ≥ 3)1.517

(1.207-1.907)<0.001*

Clinical value of circulating tumor cells (CTcs) in first-line metastatic breast cancer patients according to type of treatment and immunohistochemical molecular subtype A. Giordano1,2, M. Giuliano1,2, B.C. Handy1, N. T. Ueno1, E. Andreopoulou1, R.H.

Alvarez1, J.M. Reuben1, V. Valero1, G.N. Hortobagyi1, M. Cristofanilli3

1. M.D. Anderson Cancer Center, Houston, TX, US. 2. University of Naples Federico II, Italy. 3. Fox

Chase Cancer Center, Philadelphia, PA, US.

To evaluate the differential effect of various types of 1st line therapies (hormonal therapy, HTx; chemotherapy, CTx; anti-HER2 therapy; CTx plus Bevacizumab; mono-chemotherapy) on CTC enumeration (post-treatment CTC). We compared CTC modifications within immunohistochemical (IHC) defined subtypes of breast cancer at radiological documented progression of disease (progression CTC).

Study Aims

CTCs evaluation in 1st line MBC patients (N = 235)

Baseline CTC value: assay taken within 30 days before starting therapy;

Post-treatment CTC value: the lowest CTC value after starting therapy;

Progression CTC value: assay taken within 30 days before documented radiological progression of disease (PD).

First-line Treatment for MBC

Basaline CTC

Post-treatment CTC

Progression CTC

PD

235 (100%) 161 (69%) 105 (59%)

N = 179

N = 235

HTx (n = 25)P = .68

Anti-HER2 (n = 30)P < .0001

Poli-CTx (n = 59)P < .0001 P < .0001

Mono-CTx (n = 16)P < .0001

Bevacizumab + CTx (n= 31)

Overall (n = 161)P < .0001

Paired baseline and post-treatment CTC value according type of treatment

Time-related clinical trend of CTC in immunohistochemical (IHC) subtypes of breast cancer

Baselin

e

CTCPost-

Treatment

CTC

Progressi

on

CTCBase

line

CTCPost-

Treatment

CTC

Progressi

on

CTC

Baselin

e

CTCPost-

Treatment

CTC

Progressi

on

CTCBase

line

CTCPost-

Treatment

CTC

Progressi

on

CTC

Overall (n = 87)P < .05 P < .05

HR+/HER2- (n = 47)P < .05 P < .05

HER2+ (n = 11)P < .05 ns

TNBC (n = 29)P < .05 P < .05

San Antonio Breast Cancer Symposium - Cancer Therapy and Research Center at UT Health Science Center – December 8-12, 2010

Prognostic & predictive value of

Circulating Tumor Cells (CTC) in

metastatic breast cancer patients

treated by 1st line chemotherapy

Jean-Yves Pierga1,2,Thomas Bachelot3, Suzette Delaloge4,

Etienne Brain5, Mario Campone6, Bernard Asselain1,

Claire Mathiot1, David Hajage1, François-Clément Bidard1

1 Institut Curie, Paris, France2 Université Paris Descartes, Paris, France3 Centre Léon Bérard, Lyon, France4 Institut Gustave Roussy, Villejuif, France5 Institut Curie, Saint Cloud, France6 Centre René Gauducheau, Nantes, France

IC 2006-04 study

Main objective

To test if CTC decrease at the 2nd cycle of chemotherapy (C2) is associated

with PFS and OS (threshold ≥5 CTC /7.5ml)

N= 216 evaluable patients required

Secondary objectives

Prognostic value of CTC at baseline (PFS, OS)

at clinical and imaging evaluation (C3/C4)

Comparison with serum tumor markers (CA 15.3, LDH & CEA)

RECIST response criteria

To challenge the ≥5 CTC threshold

CTC HER2 expression (not shown)

CTC at radiological progression (not shown)

IC 2006-04 study (NCT00898014)

IC 2006-04 study (NCT00898014)

Inclusion criteriaMetastatic breast cancer patients prior to the first line of chemotherapy with

evaluable or mesurable disease (prior hormonal treatment was allowed)

Study Design

Cycle 1Cycle 1 Cycle 2Cycle 2 Cycle 3Cycle 3 Cycle 4Cycle 4

OR

CTCMarkersBiology

Imaging(RECIST)

progression

OR

1st line

CTC results were not disclosed to clinicians

5 French Cancer Centers

Median follow-up: 15 months

Progression-Free Survival

Progressions: N=162 (61%)

Median PFS: 11 months

Overall Survival

Deaths: N= 57 (21%)

Median OS: not reached

First line chemotherapy regimen

Taxanes (81%)

Anthracyclines (11%)

5-fluorouracil (9%)

Vinorelbine (3%)

Targeted therapy

Anti-HER2 therapies (17%)

Bevacizumab (47%)

267 patients were included (June 2007 – Sept 2009)

IC 2006-04 study (NCT00898014)

CTC detection at baseline & patients characteristics

Patients characteristics’ N (%) % with ≥ 5CTC P value

TOTAL 267 44% -

Premenopausal 113 (43%) 45%

Post menopausal 148 (57%) 43% 0.78

PS=0 123(48%) 29%

PS >0 132 (52%) 57% <0.0001

Grade 1-2 132 (52%) 43%

Grade 3 123 (48%) 45% 0.64

HR+ / HER2- 159 (62%) 46%

HER2+ 45 (17%) 34% 0.36

Triple neg. 54 (21%) 46%

Liver metastasis - 156 (60%) 39%

Liver metastasis + 93 (40%) 58% 0.03

Bone metastasis - 109 (42%) 28 %

Bone metastasis + 150 (58%) 56% <0.0001

<3 met. sites 155 (59%) 39%

≥3 met. sites 106 (41%) 52% 0.03

CTC detection at baseline: correlation with serum markers

Serum marker N (%) % with ≥ 5CTC P value

TOTAL 267 44% -

CA15.3 ≤N 88 (36%) 26%

CA15.3 >N 159 (64%) 53% <0.0001

CEA ≤N 103 (49%) 35%

CEA >N 109 (51%) 49% 0.03

LDH ≤N 121 (55%) 25%

LDH >N 99 (45%) 67% <0.0001

ALP ≤N 170 (71%) 36%

ALP >N 71 (29%) 65% <0.0001

Baseline CTC count was associated with PFS

p<0.0001

Baseline CTC count was associated with OS

p<0.0001

Baseline prognostic factors: PFS

Multivariate analysis

Prognostic factors

RR CI(0.95) P value

CTC <5 1.00

CTC ≥5 1.90 1.2 - 2.8 0.002

CEA ≤N 1.00

CEA >N 2.02 1.2 - 3.1 0.002

HR+ and/or HER2+

1.00

Triple neg. 4.16 2.4 - 7.0 <0.0001

PS = 0 1.00

PS > 0 2.22 1.4 - 3.4 0.0002

Baseline prognostic factors: OS

Multivariate analysis

Prognostic factors

RR CI(0.95) P value

HR+ and/or HER2+

1.00

Triple negative

4.31 2.0 - 8.8 0.0001

PS = 0 1.00

PS > 0 2.67 1.1 - 6.5 0.02

CTC <5 1.00

CTC ≥5 2.41 1.1 - 5.3 0.02

CTC changes between baseline & before C2

Progression-Free Survival

Main study endpoints: PFS p=0.04; OS p=0.01

p<0.0001

Overall Survival

p <0.0001

CTC changes differed according to treatment

Nb pts with≥5 CTC

at baseline

% with ≥5 CTC

before C2

% with ≥ 5 CTC

before C3/4

Chemo. alone N= 39 47% 38%

Chemo.+ bevacizumab

N= 60 36% 23%

Chemo.+ anti-HER2

therapyN= 15 17% 0%

Among patients with ≥5CTC at baseline,

a stronger CTC decrease was observed with targeted therapies

Molecular Characterization of CTCs

Moving forward

GeparQuinto – Decision Tree

HER2-positive?HER2-positive?

HER2+:HER2+:TrastuzumabTrastuzumabLapatinibLapatinib

nono

HER2-:HER2-:BevacizumabBevacizumabEverolimus (RAD001)Everolimus (RAD001)

yesyes

PredictivePredictive factors for these new treatment are factors for these new treatment are required…required…

CTC ?CTC ? CEC ?CEC ?

HER2 expression in CTC and corresponding primary breast tumours

Primary tumors

CTC HER2-negative HER2-positive

Before NT

After 4 cycles

Before surgery

Before NT

After 4 cycles

Before surgery

Analyzed CTC-positive cases (n)

52 31 31 19 5 5

HER2-negative (0 or 1+)

37 (71.1%)

21 (67.7%)

25 (80.6%)

6 (31.6%)

3 (60%)

3 (60%)

HER2 equivocal (2+)

8 (15.4%)

7 (22.6%)

1 (3.2%)

3 (15.8%)

2 (40%)

2 (40%)

HER2-strongly positive (3+)

7 (13.5%)

3 (9.7%)

5 (16.1%)

10 (52.6%)

0 0

* No CTC with strong HER2 expression (3+) after Herceptin or Lapatinib treatment

0 0

* Discrepancy in HER2 status between primary tumors and CTC

7(13.5%)

3(9.7%)

5(16.1%)

6(31.6%)

3(60%)

3(60%)

FISH analysis of Circulating Tumor Cells

Correlation between HER2 overexpression and HER2 amplification

HER2: 1+

HER2: 2+

HER2: 3+

Nonamplified

Nonamplified

Amplified

Meng et al. Proc Natl Acad Sci U S A. 2004;101:9393-8.

CK-FITC HER2- TR Chr 17 / HER2

FISH & Circulating Tumor CellsBreast Cancer

A CTC isolated from a patient with metastatic breast cancer. After counting the sample was dried and fixed inside the chamber and later assayed using the Repeat-free HER2 / SE 17 FISH kit.

Cytokeratin-PE & DAPI

HER2

SE17

CK-PE DAPI (nucleus)

Blood drawn at baseline prior to chemotherapy

Arm A (51 pts)

HER-2 negative

Primary and/or mets

Arm B (25 pts)

HER-2 positive

Primary and/or mets

CTCs-HER2

CTC ≥ 5

Blood drawn 3 weeks after first chemotherapy dose

Blood drawn at baseline prior to chemotherapy

HER-2 negative disease

Arm A

Standard Therapy + Trastuzumab

Arm B

Standard Therapy alone

CTCs-Targeted Therapy

CTC +/HER2+

Randomization

Primary_PFSSecondary-OS

CTCs

DNA,methylated genes and CTCs

Van der Auwera I, et al. Br J Cancer. 2009;100(8):1277-86.

DNA,methylated genes and CTCs

Schematic of the MagSweeper process.

Talasaz A H et al. PNAS 2009;106:3970-3975

The MagSweeper

Functionality of isolated cells

Ameri et al, BJC 2010

Single cell samples vs Pooled sample

Scatter plot of gene expression levels of whole transcriptome of each individual cell (FCC7, FCC8, FCC9) vs profile of pool of 3 cells (FCC7-9 AVG)

Gene Concordance

FCC7

FCC8 FCC93938 4680

4885

1029

544

5091559

1788

1326 1548

FCC7

FCC8 FCC9

Pool

2939

2409 3097

1946

1529 1583

4967

Concordance of the genes detected from each individual cell

Concordance of the genes detected from each individual cell

and pool of cells

Unassisted Clustering

H2O

Cell type O

Cell type S

Clearly breast cancer cells cluster together and separately

from other type of CTCs

AdnaTest

Comparison between circulating and disseminated tumor cells in breast cancer

16%

61%

39%

25%

2%

57%

0%

10%

20%

30%

40%

50%

60%

70%

CTC pos EpCAM MUC-1 HER2 ER PR

BM neg (%)

BM pos (%)

Total (%)

Blood neg 175 (78)

50 (22) 225 (100)

Blood pos 28 (67)

14 (33) 42 (100)

Total 203 (76)

64 (24) 267 (100) *p=0.112

Fehm T et al. Breast Cancer Res 11(4):R59. , 2009

Comparison between circulating tumor cells and primary tumor in breast cancer

Expression of ALDH1 and EMT markers in metastatic breast cancer patients undergoing chemo-, hormonal– or trastuzumab therapy

6%

19%

13% 13%

25%

58%

50%

42%

0%

10%

20%

30%

40%

50%

60%

70%

Twist Akt2 PI3K ALDH1

Marker

%Po

sitiv

es

CTC(-) CTC(+)

Ladd

er

Patie

nt1

Patie

nt2

Patie

nt3

Patie

nt4

C+

Actin

PI3K

Akt2

TwistLa

dder

Patie

nt1

Patie

nt2

Patie

nt3

Patie

nt4

C+

Actin

PI3K

Akt2

Twist

Aktas B, et al SABC 2008

HER2 levels in tumor-initiating cells of carcinoma cell lines

Magnifico A et al. Clin Cancer Res 2009;15:2010-2021

Role of Notch signaling on HER2 expression of tumor-initiating cells

Magnifico A et al. Clin Cancer Res 2009;15:2010-2021

Progression of Cancer

EMT/MET play important role during metastasis (The biology of Cancer (Garland Sciences 2007)

Fig 1. EMT/MET play important role during Metastasis (The Biology of Cancer (© Garland Science 2007)

EMT MET

PrimaryTumor Intravasation

TransportVia

circulation

Arrest in microvessels of

organsExtravasation

Micrometastasis Metastasis

Epithelial-Mesenchymal Transition (EMT)

Mesenchymal-EpithelialTransition (MET)

E-cadherin-catenin-cateninEpCAMVimentinFibronectinN-cadherin

E-cad -CK+/-

EpCAM –

The epithelial-mesenchymal transition generates cells with properties of stem cells

Mani SA et al, Cell 133(4):704-15,2008

Heterogeneity of CTC

EpCAM

TWISTHMLE

VectorHMLE

positivecontrol

negativecontrol

Ladder

ADNA Test CellSearch (Veridex)

CONTROLHigh range: 522-1218; High Control: 1016 ; PassLow range: 17-67; Low Control: 42; Pass

TWIST HMLE# of CTC: 0

Vector HMLE# of CTC: 55

ACTINFig 1. Conventional Tests for CTCs Fail to detect humanmammary epithelial cells induced to undergo EMT by overexpression of TWIST1. TWIST1 was overexpressedin Immortalized human mammary epithelial cells , whichresulted in acquisition of a mesenchymal phenotype and stem-like properties as evidenced by morphology, gene expressionanalysis., and mammosphere assays. Two hundred cells werethen spiked into peripheral blood from normal patients andanalyzed by the ADNA and CellSearch methods.

Mego et al. Int J Cancer. 2011

Heterogeneity of CTC

Mego, M., Mani S. A. & Cristofanilli, M. (2010), Nat. Rev. Clin. Oncol.

Conclusions CTCs in patients with MBC

• An independent prognostic factor• Should be used for risk stratification and therapeutic

monitoring • Phenotypic analysis of CTCs suggests an heterogeneous but

independent phenotype • Evaluation of other technology platforms for molecular

characterization Future Prospective studies:

• Further characterize CTC phenotype, genotype (stem cells markers, HER-2)

• Prospective multicenter studies to validate the concept of CTCs targeted therapies

Acknowledgments

MD Anderson Cancer Center Fox Chase Cancer Center

James M Reuben, PhD Kathy R Alpaugh, PhDNaoto T Ueno, MD, PhD Ramona Swaby, MDAnthony Lucci, MD Kevin Johnson, PhDSavitri Krishnamurthy, MD Zhaomei Mu, MDSendurai Mani, PhD Catherine A Bingham, PhDBalraj Singh, PhDWendy Woodward, MD, PhDHerbert Fritsche, PhDYang, Li-Ying, PhD