Abstract PS16-04: Denosumab as an enhancer of the immune infiltrate in hormone receptor-positive early breast cancer. Subgroup analysis from the D-Biomark window-of-opportunity clinical trial (NCT03691311)
Authors: Vethencourt Andrea , Trinidad Eva , Dorca Eduard , Petit Anna , Soler-Monsó Teresa , Stradella Agostina , Capo Cristina , Urriticoechea Ander , Matas Marta , Pérez-Chacon Gema , Jimenez María , Ciscar Marina , Brizzi Emilia , Alcaide Gonzalo Soria , Gomez Gonzalo , Piñeiro Elena , Purqueras Elvira , Garcia Amparo , Iserte Ariadna , Pla M Jesus , Campos Miriam , Gil-Gil Miguel , Pernas Sonia , Gonzalez-Suarez Eva , Falo Catalina 
Published: May 2024

Abstract
Background:
The receptor activator of nuclear factor κB (RANK) signaling pathway has emerged as a therapeutic target in breast cancer (BC). Recent studies indicate that inhibition of the RANK pathway induces tumor cell differentiation and may enhance the anti-tumor immune response. The D-Biomark clinical trial aims to evaluate the antitumor (antiproliferative and proapoptotic) and immunomodulatory effects of denosumab in HER2-negative early BC.
Methods:
Patients with early HER2-negative BC scheduled for primary surgery were randomized in a 2:1 ratio to receive two doses of 120 mg denosumab on days 1 and 8 vs no treatment before surgery.
Immunohistochemistry (IHC) was used to assess Ki67 (proliferation), cleaved caspase-3 (cell survival), RANK and RANKL. Stromal tumor infiltrating lymphocytes (TILs) and serum markers including free RANKL (sRANKL), tartrate-resistant acid phosphatase 5b (TRACP5b), and osteoprotegerin (OPG) were also analyzed. Paired t-test was used to compare values between core biopsy (biopsy A) and surgical samples (biopsy B). Subgroup analysis by intrinsic subtype was performed on 47 matched cases using PAM50.
Results:
Between July 2019 and May 2021, we enrolled 60 patients, 58 evaluable, including 10 triple-negative breast cancer (TNBC). The clinicopathologic characteristics of the population at the time of enrollment were well balanced, but the TNBC recruited included 5 out of 10 tumors with a more indolent behavior than the typical tumors of this lineage (apocrine tumors, low cell proliferation). Due to this and the small number of cases, no conclusions can be drawn in this subgroup. RANK expression was detected in 19 tumor cases, while 17 cases expressed RANKL. The treated group showed a decrease in sRANKL (p &lt; 0.000), indicating denosumab activity, while the control group showed no change (p1.0). OPG levels in the experimental group showed a non-significant increase (p0.07), while TRACP5b remained unchanged. Both groups showed a non-clinically relevant increase in cell proliferation (5 percentage points), control p0.04, experimental p0.01. Subgroup analysis of tumors with RANK+ or RANKL+ tumor cells also showed no reduction in Ki67. Cell survival did not decrease in the overall cohort (control p0.05, experimental p0.24), nor in subgroups or in tumors with RANK+ or RANKL+ tumor cells. Denosumab treatment increased TILs in the overall population (control p0.06, experimental p0.0006) and in the subgroups: RANK+ tumors, RANKL+ tumors, premenopausal and postmenopausal, less so in the TNBC group. The subgroup analysis is shown in Table 1. Analysis by intrinsic subtype showed that in the experimental group there was an increase in cases with a change to luminal A lineage (17%) compared to the control group (6%), suggesting a possible cellular differentiation towards less aggressive tumors. Although the number of patients is small, these changes warrant further investigation and highlight the role of denosumab as an immune activator in these luminal tumors known for their low inflammatory infiltrate.
Conclusion:
Two doses of denosumab prior to surgery did not reduce proliferation or increase apoptosis. However, this short course of denosumab increased TILs in early BC, particularly in luminal tumors, and may induce tumor cell differentiation into luminal A-like tumors.
Table.
Citation Format: Andrea Vethencourt, Eva Trinidad, Eduard Dorca, Anna Petit, Teresa Soler-Monsó, Agostina Stradella, Cristina Capo, Ander Urriticoechea, Marta Matas, Gema Pérez-Chacon, María Jimenez, Marina Ciscar, Emilia Brizzi, Gonzalo Soria Alcaide, Gonzalo Gomez, Elena Piñeiro, Elvira Purqueras, Amparo Garcia, Ariadna Iserte, M Jesus Pla, Miriam Campos, Miguel Gil-Gil, Sonia Pernas, Eva Gonzalez-Suarez, Catalina Falo. Denosumab as an enhancer of the immune infiltrate in hormone receptor-positive early breast cancer. Subgroup analysis from the D-Biomark window-of-opportunity clinical trial (NCT03691311) [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PS16-04.