Abstract P3-05-02: Detection of activating estrogen receptor 1 (ESR1) in circulating tumor DNA (ctDNA) in hormone-receptor positive metastatic breast cancer (MBC)
Authors: Austin L , Rodriguez A , Jaslow R , Fortina P , Nagy R , Zill O , Talasaz A , Cristofanilli M 
Published: May 2016

Abstract
Background
About 65% of breast cancers express the estrogen receptor α and the mainstay of treatment are therapies that result in estrogen receptor modulation (selective estrogen receptor modulators, SERMs) or estrogen deprivation (aromatase inhibitors, AIs). Even though endocrine therapy has resulted in reduced recurrence and mortality, a significant portion of patients relapse with metastatic disease and subsequently progress while on therapy for advanced disease (endocrine resistance). Recent evidence showed that activating hot spot mutations in the ligand binding domain of the ERα (ESR1) are acquired on treatment (frequency of 20%) and can drive resistance to endocrine therapy, especially AIs. ESR1 mutations can be detected by evaluation of circulating tumor DNA (ctDNA), a method where circulating DNA fragments with tumor-specific sequence alterations are identified in the blood of patients.
Methods
This is a retrospective evaluation of 9 patients with hormone receptor positive (HR+) metastatic breast cancer (MBC) who had progressed on multiple lines of endocrine therapy (ET) and were found to have ESR1 mutations in ctDNA. Patients had blood drawn for ctDNA analysis either at progression to serve as a baseline before starting a new regimen or to monitor response to ongoing treatment. Guardant360™(Guardant Health) involves ctDNA isolation from plasma using a Qiagen circulating nucleic acid kit, then a panel of 68 gene mutations associated with solid tumors as reported in the COSMIC database sequenced using single-molecule digital sequencing technology.
Results
All of the patients had MBC and were luminal subtype except for one HER2+, and most had invasive ductal carcinoma although 2 patients were invasive lobular carcinoma (22%). Most patients had both bone and visceral involvement (78%), only two patients had bone only metastasis. The patients were generally heavily pretreated with an average of 3 lines of ETs and 6 lines of therapy altogether (chemotherapy + ET). Duration on endocrine therapy ranged from 23 months to 7 years (mean 4.3 years). All patients were found to have ESR1 mutations on ctDNA, the range of percentage of mutant allele was 0.28-23.76%. Three patients had tissue sent for NGS and none of the tissue samples had an ESR1 mutation detected although they were biopsied at various time points in treatment. One of those patients had two ESR1 mutations in ctDNA, which were not detected on tissue sent for NGS one year prior, and had not been on ET for several years. One patient with abdominal carcinomatosis from lobular carcinoma who had been on ETs therapies for 6 years was found to have 4 distinct ESR1 mutations in a single blood draw, suggesting sub-clonal evolution of resistance. One patient also had 5 circulating tumor cells, all of which had ESR1 mutations detected when circulating tumor cells were individually sequenced.
Conclusions
ctDNA is a sensitive test for detection of ESR1 in HR+ MBC patients, with the advantage of being a blood based assay which lends itself to serial analysis. In this patient population ctDNA can be a helpful tool to predict response to ET and predict treatment failure.
Citation Format: Austin L, Rodriguez A, Jaslow R, Fortina P, Nagy R, Zill O, Talasaz A, Cristofanilli M. Detection of activating estrogen receptor 1 (ESR1) in circulating tumor DNA (ctDNA) in hormone-receptor positive metastatic breast cancer (MBC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-05-02.