Liquid biopsy-based technologies: a promising tool for biomarker identification in her2-low breast cancer patients for improved therapeutic outcomes

Abstract

The molecular classification of breast cancer plays a pivotal role in developing personalized treatment strategies, with the aim of improving therapeutic outcomes. Despite significant advancements, current diagnostic workflows are hindered by several challenges, including pre-analytical variability, interpretive ambiguity, and inconsistencies in threshold definitions, particularly in cases involving human epidermal growth factor receptor 2 (HER2)-low breast cancer. In this context, liquid biopsy technologies have emerged as promising tools for refining breast cancer diagnostics. Techniques such as circulating tumor DNA and circulating tumor cell analysis provide a non-invasive approach to assessing tumor-associated biomarkers. These methodologies are particularly advantageous for analyzing low-abundance materials, such as formalin-fixed paraffin-embedded samples and liquid biopsies, thus enhancing the precision of molecular classification and informing more targeted therapeutic decisions for breast cancer patients. This review aims to explore the potential of liquid biopsy in addressing the limitations of current diagnostic practices, with a specific focus on its application in HER2-low breast cancer. Furthermore, it advocates for a transition toward high-throughput RNA-based screening and quantification, which may address critical unmet clinical needs.

Keywords

microRNA / blood / biomarker / breast cancer / HER2

References

[1] Eliyatkın N,Zengel B,Vardar E.Molecular classification of breast carcinoma: from traditional, old-fashioned way to a new age, and a new way.J Breast Health2015;11:59-66 PMCID:PMC5351488

[2] Dunnwald LK,Li CI.Hormone receptor status, tumor characteristics, and prognosis: a prospective cohort of breast cancer patients.Breast Cancer Res2007;9:R6 PMCID:PMC1851385

[3] Shirman Y,Shai A.HER2-low breast cancer: current landscape and future prospects.Breast Cancer2023;15:605-16 PMCID:PMC10439285

[4] Ergun Y,Akagunduz B.Comparison of HER2-zero and HER2-low in terms of clinicopathological factors and survival in early-stage breast cancer: a systematic review and meta-analysis.Cancer Treat Rev2023;115:102538

[5] Moutafi M,Yaghoobi V.Quantitative measurement of HER2 expression to subclassify ERBB2 unamplified breast cancer.Lab Invest2022;102:1101-8

[6] Modi S,Yamashita T.Trastuzumab deruxtecan in previously treated HER2-low advanced breast cancer.N Engl J Med2022;387:9-20

[7] Rogawski D,Ma Q.Durable responses to trastuzumab deruxtecan in patients with leptomeningeal metastases from breast cancer with variable HER2 expression.J Neurooncol2024;170:209-17

[8] Nikanjam M,Kurzrock R.Liquid biopsy: current technology and clinical applications.J Hematol Oncol2022;15:131 PMCID:PMC9465933

[9] Scaltriti M,Bradbury I.High HER2 expression correlates with response to the combination of lapatinib and trastuzumab.Clin Cancer Res2015;21:569-76

[10] Swain SM,Hamilton E.Targeting HER2-positive breast cancer: advances and future directions.Nat Rev Drug Discov2023;22:101-26 PMCID:PMC9640784

[11] Wolff AC,Allison KH.Human epidermal growth factor receptor 2 testing in breast cancer: American society of clinical oncology/college of American pathologists clinical practice guideline focused update.J Clin Oncol2018;36:2105-22

[12] Early Breast Cancer Trialists’ Collaborative group (EBCTCG). Trastuzumab for early-stage, HER2-positive breast cancer: a meta-analysis of 13 864 women in seven randomised trials.Lancet Oncol2021;22:1139-50

[13] Iqbal N.Human epidermal growth factor receptor 2 (HER2) in cancers: overexpression and therapeutic implications.Mol Biol Int2014;2014:852748 PMCID:PMC4170925

[14] Geiersbach KB,Meyer RG.HER2 testing for breast cancer in the genomics laboratory: a sea change for fluorescence in situ hybridization.Arch Pathol Lab Med2021;145:883-6

[15] Schettini F,Brasó-Maristany F.Clinical, pathological, and PAM50 gene expression features of HER2-low breast cancer.NPJ Breast Cancer2021;7:1 PMCID:PMC7782714

[16] Marchiò C,Marques A,Berrino E.Evolving concepts in HER2 evaluation in breast cancer: Heterogeneity, HER2-low carcinomas and beyond.Semin Cancer Biol2021;72:123-35

[17] Ahn S,Lee K.HER2 status in breast cancer: changes in guidelines and complicating factors for interpretation.J Pathol Transl Med2020;54:34-44 PMCID:PMC6986968

[18] Fernandez AI,Bellizzi A.Examination of low ERBB2 protein expression in breast cancer tissue.JAMA Oncol2022;8:1-4 PMCID:PMC8814969

[19] Guerini-Rocco E,Cursano G.Standardized molecular pathology workflow for ctDNA-based ESR1 testing in HR+/HER2- metastatic breast cancer.Crit Rev Oncol Hematol2024;201:104427

[20] Couturier J,Nicolas A.Strong correlation between results of fluorescent in situ hybridization and immunohistochemistry for the assessment of the ERBB2 (HER-2/neu) gene status in breast carcinoma.Mod Pathol2000;13:1238-43

[21] Lebeau A,Kaltz C.Her-2/neu analysis in archival tissue samples of human breast cancer: comparison of immunohistochemistry and fluorescence in situ hybridization.J Clin Oncol2001;19:354-63

[22] Godoy-Ortiz A,Chica Parrado MR.Deciphering HER2 breast cancer disease: biological and clinical implications.Front Oncol2019;9:1124 PMCID:PMC6828840

[23] Sørlie T,Tibshirani R.Gene expression patterns of breast carcinomas distinguish tumor subclasses with clinical implications.Proc Natl Acad Sci USA2001;98:10869-74 PMCID:PMC58566

[24] Perou CM,Eisen MB.Molecular portraits of human breast tumours.Nature2000;406:747-52

[25] The Cancer Genome Atlas Network. Comprehensive molecular portraits of human breast tumours.Nature2012;490:61-70 PMCID:PMC3465532

[26] Prat A,Adamo B.Clinical implications of the intrinsic molecular subtypes of breast cancer.Breast2015;24 Suppl 2:S26-35

[27] Lesurf R,Griffith M.Genomic characterization of HER2-positive breast cancer and response to neoadjuvant trastuzumab and chemotherapy-results from the ACOSOG Z1041 (Alliance) trial.Ann Oncol2017;28:1070-7 PMCID:PMC5790063

[28] Benöhr P,Speer R.Her-2/neu expression in breast cancer - A comparison of different diagnostic methods.Anticancer Res2005;25:1895-900

[29] Paik S,Tang G.A multigene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer.N Engl J Med2004;351:2817-26

[30] van’t Veer LJ,van de Vijver MJ.Gene expression profiling predicts clinical outcome of breast cancer.Nature2002;415:530-6

[31] Gjerdrum LM,Kjeldsen E,Nexo E.Real-time quantitative PCR of microdissected paraffin-embedded breast carcinoma: an alternative method for HER-2/neu analysis.J Mol Diagn2004;6:42-51 PMCID:PMC1867459

[32] Bastien RR,Ebbert MT.PAM50 breast cancer subtyping by RT-qPCR and concordance with standard clinical molecular markers.BMC Med Genomics2012;5:44 PMCID:PMC3487945

[33] Chia SK,Tu D.A 50-gene intrinsic subtype classifier for prognosis and prediction of benefit from adjuvant tamoxifen.Clin Cancer Res2012;18:4465-72 PMCID:PMC3743663

[34] Dowsett M,Lopez-Knowles E.Comparison of PAM50 risk of recurrence score with oncotype DX and IHC4 for predicting risk of distant recurrence after endocrine therapy.J Clin Oncol2013;31:2783-90

[35] Gnant M,Greil R.Predicting distant recurrence in receptor-positive breast cancer patients with limited clinicopathological risk: using the PAM50 risk of Recurrence score in 1478 postmenopausal patients of the ABCSG-8 trial treated with adjuvant endocrine therapy alone.Ann Oncol2014;25:339-45

[36] Prat A,Thomas M.Research-based PAM50 subtype predictor identifies higher responses and improved survival outcomes in HER2-positive breast cancer in the NOAH study.Clin Cancer Res2014;20:511-21

[37] Wang F,Su N.RNAscope: a novel in situ RNA analysis platform for formalin-fixed, paraffin-embedded tissues.J Mol Diagn2012;14:22-9

[38] Allison KH,Schmidt RA.Frequency of HER2 heterogeneity by fluorescence in situ hybridization according to CAP expert panel recommendations: time for a new look at how to report heterogeneity.Am J Clin Pathol2011;136:864-71

[39] Bartlett AI,Robson T.Heterogeneous HER2 gene amplification: impact on patient outcome and a clinically relevant definition.Am J Clin Pathol2011;136:266-74

[40] Hanna WM,Bilous M.HER2 in situ hybridization in breast cancer: clinical implications of polysomy 17 and genetic heterogeneity.Mod Pathol2014;27:4-18

[41] Lee K,Choi J.Genomic analysis of plasma circulating tumor DNA in patients with heavily pretreated HER2 + metastatic breast cancer.Sci Rep2023;13:9928 PMCID:PMC10279711

[42] Tierno D,Zanconati F,Scaggiante B.An overview of circulating cell-free nucleic acids in diagnosis and prognosis of triple-negative breast cancer.Int J Mol Sci2023;24:1799 PMCID:PMC9864244

[43] Basu AS.Digital assays part II: digital protein and cell assays.SLAS Technol2017;22:387-405

[44] Zhu Y,Lira ME.Droplet digital polymerase chain reaction detection of HER2 amplification in formalin fixed paraffin embedded breast and gastric carcinoma samples.Exp Mol Pathol2016;100:287-93

[45] Ferrari A,Pivot X.A whole-genome sequence and transcriptome perspective on HER2-positive breast cancers.Nat Commun2016;7:12222

[46] Zhao S,Jin X.Molecular portraits and trastuzumab responsiveness of estrogen receptor-positive, progesterone receptor-positive, and HER2-positive breast cancer.Theranostics2019;9:4935-45 PMCID:PMC6691389

[47] Li K,Chen B.Genetic mutation profile of Chinese HER2-positive breast cancers and genetic predictors of responses to Neoadjuvant anti-HER2 therapy.Breast Cancer Res Treat2020;183:321-32 PMCID:PMC7383038

[48] Omarini C,Manfredini S.Modulation of mutational landscape in HER2-positive breast cancer after neoadjuvant chemotherapy.Transl Oncol2020;13:100794 PMCID:PMC7264751

[49] Li J,Bao Y.HER2-L755S mutation induces hyperactive MAPK and PI3K-mTOR signaling, leading to resistance to HER2 tyrosine kinase inhibitor treatment.Cell Cycle2019;18:1513-22 PMCID:PMC6592242

[50] Georgescu MM.PTEN tumor suppressor network in PI3K-Akt pathway control.Genes Cancer2010;1:1170-7 PMCID:PMC3092286

[51] Piccart M,Fumagalli D.Adjuvant pertuzumab and trastuzumab in early HER2-positive breast cancer in the APHINITY trial: 6 years’ follow-up.J Clin Oncol2021;39:1448-57

[52] Stern HM,Burzykowski T.PTEN loss is associated with worse outcome in HER2-amplified breast cancer patients but is not associated with trastuzumab resistance.Clin Cancer Res2015;21:2065-74 PMCID:PMC4417419

[53] Kukurba KR.RNA sequencing and analysis.Cold Spring Harb Protoc2015;2015:951-69 PMCID:PMC4863231

[54] Lee HB,Kim M.Development and validation of a next-generation sequencing-based multigene assay to predict the prognosis of estrogen receptor-positive, HER2-negative breast cancer.Clin Cancer Res2020;26:6513-22

[55] Morsberger L,Long P.HER2 amplification by next-generation sequencing to identify HER2-positive invasive breast cancer with negative HER2 immunohistochemistry.Cancer Cell Int2022;22:350 PMCID:PMC9664724

[56] Mittempergher L,Witteveen AT.MammaPrint and BluePrint molecular diagnostics using targeted RNA next-generation sequencing technology.J Mol Diagn2019;21:808-23

[57] Pfarr N,Endris V.Targeted next-generation sequencing enables reliable detection of HER2 (ERBB2) status in breast cancer and provides ancillary information of clinical relevance.Genes Chromosomes Cancer2017;56:255-65

[58] Sajjadi E,De Camilli E.Pathological identification of HER2-low breast cancer: tips, tricks, and troubleshooting for the optimal test.Front Mol Biosci2023;10:1176309 PMCID:PMC10106673

[59] Baldacchino S,Scerri J,Grech G.Optimization of a multiplex RNA-based expression assay using breast cancer archival material.J Vis Exp2018;138:57148 PMCID:PMC6126584

[60] Tighe PJ,Todd I.ELISA in the multiplex era: potentials and pitfalls.Proteomics Clin Appl2015;9:406-22 PMCID:PMC6680274

[61] Wharton KA Jr,Manesse M,Leiss F.Tissue multiplex analyte detection in anatomic pathology - pathways to clinical implementation.Front Mol Biosci2021;8:672531 PMCID:PMC8353449

[62] Clancy JW.Tumor-derived extracellular vesicles: multifunctional entities in the tumor microenvironment.Annu Rev Pathol2023;18:205-29 PMCID:PMC10410237

[63] Zhao H,Iessi E.The key role of extracellular vesicles in the metastatic process.Biochim Biophys Acta Rev Cancer2018;1869:64-77 PMCID:PMC5800973

[64] Contreras-Naranjo JC,Ugaz VM.Microfluidics for exosome isolation and analysis: enabling liquid biopsy for personalized medicine.Lab Chip2017;17:3558-77 PMCID:PMC5656537

[65] Alhajj M,Farhana A. Enzyme linked immunosorbent assay. FL: StatPearls Publishing, 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555922/ [Last accessed on 29 Oct 2024]

[66] Im K,Diaz MFP.An introduction to performing immunofluorescence staining.Methods Mol Biol2019;1897:299-311 PMCID:PMC6918834

[67] El-Deiry WS,Lenz HJ.The current state of molecular testing in the treatment of patients with solid tumors, 2019.CA Cancer J Clin2019;69:305-43 PMCID:PMC6767457

[68] Im H,Park YI.Label-free detection and molecular profiling of exosomes with a nano-plasmonic sensor.Nat Biotechnol2014;32:490-5 PMCID:PMC4356947

[69] Lindeman NI,Aisner DL.Updated molecular testing guideline for the selection of lung cancer patients for treatment with targeted tyrosine kinase inhibitors: guideline from the college of American pathologists, the international association for the study of lung cancer, and the association for molecular pathology.J Mol Diagn2018;20:129-59

[70] Abrahamsen HN,Nexo E,Sorensen BS.Towards quantitative mRNA analysis in paraffin-embedded tissues using real-time reverse transcriptase-polymerase chain reaction: a methodological study on lymph nodes from melanoma patients.J Mol Diagn2003;5:34-41 PMCID:PMC1907376

[71] Macabeo-Ong M,Dekker N.Effect of duration of fixation on quantitative reverse transcription polymerase chain reaction analyses.Mod Pathol2002;15:979-87

[72] Dunbar SA.Nucleic acid sample preparation techniques for bead-based suspension arrays.Methods2023;219:22-9

[73] Flagella M,Zheng Z.A multiplex branched DNA assay for parallel quantitative gene expression profiling.Anal Biochem2006;352:50-60

[74] Knudsen BS,McLerran DF.Evaluation of the branched-chain DNA assay for measurement of RNA in formalin-fixed tissues.J Mol Diagn2008;10:169-76 PMCID:PMC2259472

[75] Duenwald S,Wang Y.Development of a microarray platform for FFPET profiling: application to the classification of human tumors.J Transl Med2009;7:65 PMCID:PMC2732596

[76] Cisneros-Villanueva M,Rios-Romero M.Cell-free DNA analysis in current cancer clinical trials: a review.Br J Cancer2022;126:391-400 PMCID:PMC8810765

[77] Connal S,Sala A.Liquid biopsies: the future of cancer early detection.J Transl Med2023;21:118 PMCID:PMC9922467

[78] Hoeben A,van den Beuken-van Everdingen MHJ.Personalized medicine: recent progress in cancer therapy.Cancers2021;13:242 PMCID:PMC7826530

[79] Haslam A,Prasad V.Updated estimates of eligibility for and response to genome-targeted oncology drugs among US cancer patients, 2006-2020.Ann Oncol2021;32:926-32

[80] Haslam A.Estimation of the percentage of US patients with cancer who are eligible for and respond to checkpoint inhibitor immunotherapy drugs.JAMA Netw Open2019;2:e192535 PMCID:PMC6503493

[81] Lamba N,Iorgulescu JB.Use of first-line immune checkpoint inhibitors and association with overall survival among patients with metastatic melanoma in the anti-PD-1 era.JAMA Netw Open2022;5:e2225459 PMCID:PMC9412220

[82] Bayat Mokhtari R,Baluch N.Combination therapy in combating cancer.Oncotarget2017;8:38022-43 PMCID:PMC5514969

[83] Yu C,Yang J.Combination of immunotherapy with targeted therapy: theory and practice in metastatic melanoma.Front Immunol2019;10:990 PMCID:PMC6513976

[84] Zhu L,Yang L.Minimal residual disease (MRD) detection in solid tumors using circulating tumor DNA: a systematic review.Front Genet2023;14:1172108 PMCID:PMC10448395

[85] Gambardella V,Cejalvo JM.Personalized medicine: recent progress in cancer therapy.Cancers2020;12:1009 PMCID:PMC7226371

[86] Zhang W.Advances in cancer early diagnosis with liquid biopsy-based approaches.J Cancer Metastasis Treat2021;7:22 PMCID:PMC8064408

[87] Mazzitelli C,Corradini AG.Liquid biopsy in the management of breast cancer patients: where are we now and where are we going.Diagnostics2023;13:1241 PMCID:PMC10092978

[88] Palacín-Aliana I,Asensi-Puig A,González-Rumayor V.Clinical utility of liquid biopsy-based actionable mutations detected via ddPCR.Biomedicines2021;9:906 PMCID:PMC8389639

[89] Baev V,Costa-Silva B.Liquid biopsy: current status and future perspectives.Cancers2023;15:3205 PMCID:PMC10296134

[90] Takahashi RU,Hironaka A.The role of extracellular vesicle microRNAs in cancer biology.Clin Chem Lab Med2017;55:648-56

[91] Lone SN,Masoodi T.Liquid biopsy: a step closer to transform diagnosis, prognosis and future of cancer treatments.Mol Cancer2022;21:79 PMCID:PMC8932066

[92] Moding EJ,Alizadeh AA.Detecting liquid remnants of solid tumors: circulating tumor DNA minimal residual disease.Cancer Discov2021;11:2968-86 PMCID:PMC8976700

[93] Kilgour E,Brady G.Liquid biopsy-based biomarkers of treatment response and resistance.Cancer Cell2020;37:485-95

[94] Berger MF.The emerging clinical relevance of genomics in cancer medicine.Nat Rev Clin Oncol2018;15:353-65 PMCID:PMC6658089

[95] O’Leary B,Huang X.Circulating tumor DNA markers for early progression on Fulvestrant with or without palbociclib in ER+ advanced breast cancer.J Natl Cancer Inst2021;113:309-17 PMCID:PMC7936069