Abstract P5-01-08: Landscape of circulating tumor DNA (ctDNA) in metastatic breast cancer
Authors: Davis Andrew A , Jacob Saya , Gerratana Lorenzo , Shah Ami N , Wehbe Firas , Katam Neelima , Zhang Qiang , Flaum Lisa , Siziopikou Kalliopi , Platanias Leonidas C , Gradishar William J , Behdad Amir , Cristofanilli Massimo 
Published: March 2020

Abstract
Background: The clinical utility of routine clinical assessment of ctDNA in metastatic breast cancer (MBC) has not been clearly established. Recently, the Food and Drug Administration approved alpelisib (Piqray®) with a ctDNA-based companion diagnostic. Therefore, there is significant interest in describing the landscape of ctDNA alterations and establishing further clinical utility of this assessment.
Methods: We retrospectively identified ctDNA data from a single institution (Northwestern University). All patients had next-generation sequencing performed by Guardant Health (Redwood City, CA) from 2015-2019 for clinical evaluation, and patients were consented for participation in a prospective registry study. Reports were evaluated for type of genomic alterations, number of alterations, and mutant allele frequency (MAF) of the dominant clone. Clinical information including demographics, pathology, imaging, treatment, and response data were collected via patient chart review. Associations were tested through Fisher’s exact test or Kruskal-Wallis test as statistically appropriate. Matched paired samples were investigated through McNemar test.
Results: The cohort consisted of 255 patients with MBC. In total, 371 ctDNA reports were reviewed, including 116 patients with serial assessments. Baseline ctDNA evaluation occurred at a median of 3 lines of therapy (interquartile range (IQR): 1 - 5). Median number of alterations was 4 (IQR: 2-7), while median MAF was 4% (IQR: 0.6% - 17.9%). Across the entire cohort, PIK3CA and TP53 were the most commonly detected mutations, while MYC, FGFR1, PIK3CA, and ERBB2 were the most commonly detected amplifications. 40% of patients had PIK3CA aberrations observed in the analyzed plasma samples (28% amplification, 22% H1047R, 11% E542K), which was independent of breast cancer subtype. In the subset of patients with hormone-receptor positive (HR+) breast cancer, 30% of patients had ESR1 mutations (27% D538G, 19% Y537S, 12% Y537N, 11% E380Q). Patients with triple negative breast cancer (TNBC) had statistically higher MAF compared to HR+ or HER2+ breast cancer (P&lt;0.05). However, there were no differences in the number of alterations observed in each subtype. When examining the mutational profile of subtypes across lines of therapy, only ESR1 and FGFR1 were associated with collection beyond the first line of therapy for HR+ patients (P=0.003 and P&lt;0.025, respectively). The mutational profiles of TNBC and HER2+ subtypes did not vary by lines of therapy at baseline blood collection. Number of genomic alterations detected increased incrementally with increasing lines of therapy (P&lt;0.01), with specific genes more likely to be altered beyond the first line (ESR1, FGFR1, NF1). Higher MAF and number of genomic alterations were also significantly associated with number of metastatic sites on imaging (both P&lt;0.001). In the subset of patients with serial blood collections, across all patients, the following genomic alterations were significantly more likely to emerge over time in paired samples: APC, BRAF, CCNE1, ERBB2, MET, MYC, NF1 (all P&lt;0.05 with Q values corrected for multiplicity).
Conclusion: Liquid biopsy evaluation using ctDNA identified clinically meaningful genomic alterations at high frequency. In addition, our data indicate the potential clinical utility of ctDNA as a surrogate for tumor burden on imaging based on the observed correlation with lines of therapy received and sites of disease. Serial assessment of ctDNA demonstrated clonal evolution, particularly in the HR+ cohort, and identified resistant clones. Validation with an independent cohort is warranted.
Citation Format: Andrew A Davis, Saya Jacob, Lorenzo Gerratana, Ami N Shah, Firas Wehbe, Neelima Katam, Qiang Zhang, Lisa Flaum, Kalliopi Siziopikou, Leonidas C Platanias, William J Gradishar, Amir Behdad, Massimo Cristofanilli. Landscape of circulating tumor DNA (ctDNA) in metastatic breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-01-08.