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Breast cancer with HER 2 overexpressed. From laboratory to clinical practice


Academic year: 2022

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HER2 (also known as erbB2) and its relatives HER1 (epidermal growth factor receptor; EGFR), HER3 and HER4 belong to the HER family of receptor tyrosine kinases. A large family of ligands (reviewed in(1) induces receptor dimerization, with each ligand favoring some dimeric combinations over others in a specific hie- rarchical order, with a marked preference for HER2 as a dimer partner (2,3). In normal cells, activation of this receptor tyrosine kinase family triggers a rich net- work of signaling pathways that control normal cell growth, differentiation, moti- lity and adhesion in several cell lineages (4-8). The formation of heterodimers and the ensuing activation are temporary and spatially controlled in normal cells and tissue, but dysregulation of this network due to increase expression levels of HER2 (9,10) provided a growth advantage. Indeed, overexpression of HER2, which occurs in about 25% of breast cancers (11), activates the “survival” pathway, and favors cell proliferation (10,12-14). The tumorigenic action of HER2 is not limited to a poten- tial proliferative effect. In fact, HER2 has been shown to be a metastasis-promoting factor. Changes in HER2 levels and in its activation by different EGF-like and here- gulins (HRGs) ligands have been associated with increased invasiveness in vitro and a more metastatic phenotype in vivo. Notwithstanding the abundance of studies on the biology of HER2 and its receptor family, many pathways interacting with HER2 are still not fully understood or exploited for therapeutic purposes.


The availability of new molecular biology techniques has allowed a new subset clas- sification of breast carcinomas based on the gene expression profile revealed by microarray analysis (15,16). HER2 overexpression, which is associated with overex-

overexpressed. From laboratory to clinical practice

S. Menard


pression of other genes that are probably co-amplified in the same amplicon, toge- ther with a series of other co-expressed genes, has been reported to identify a parti- cular subset of tumors characterized by the lack of expression of genes associated with hormone receptor signaling pathway; high-level expression of a cluster of genes associated with proliferation; and expression of keratins related to undifferen- tiated stem cells (17-19). These findings suggest a pattern of gene expression pecu- liar to HER2-expressing tumors, and raise the possibility that all the clinical features thus far associated with HER2, e.g., prognosis, prediction of response to therapy, might actually be related to the biological behaviors of the subset and not directly to the presence of the oncoprotein. For example, sensitivity to anthracyclins might be related to the growth characteristics of the HER2-expressing subset rather than to the HER2 receptor pathway itself, as also suggested by in vitro studies (20).


The 3 well-defined risk factors for breast carcinomas development are not related with the onset of this subset of tumors. Indeed, tumors genetically-determined by Brca1 and Brca2 mutations display no alteration in HER2. Also hormone-related risk factors are not relevant for HER2-positive tumors. Indeed, in patients from ‘protected’ group, as for example those with more than 3 children and those with late menarche, the fre- quency of HER2 positivity increases since the total number of tumors in lower (pro- tected group) with no reduction of those with HER2 (21). Also irradiation, the third variable known to be associated with breast carcinoma appears to be not involved in HER2 overexpression. Indeed, in a small series of breast carcinomas from patients irradiated for Hodgkin lymphoma, no noteworthy increase in HER2 positivity was observed. It seems therefore that the cause of HER2 amplification is still to be identi- fied. Since HER2 overexpression is more frequent in young patients, these tumors are likely associated with an early event during the life (Figure 1).

Figure 1 - HER2-positivity according to age at diagnosis



Since HER2 identifies a particular subset with peculiar progression, it is important to identify it correctly. The advent of standardized, FDA-approved tests for protein overexpression by immunohistochemistry (IHC) or gene amplification by FISH (Figure 2) has led to an overall improvement in HER2 status assessment (22-25) as indicated by several quality control studies performed around the world (26-28).

However, evaluation even with standardized IHC methodology has demonstrated still some difficulties in the HER2 status determination, mainly in the tumors with intermediate expression (2+) and the HER2 signature may help in these cases.

Stability of HER2 amplification has been recently questioned (29) but new more convincing data are required.

Figure 2 - Immunohistochemistry score 3+, 2+ and Neg. and FISH with amplification


Various clinical studies have evaluated the relationship between HER2 and breast cancer outcome, and most have shown that women with HER2-positive tumors have a poorer prognosis than women with HER2-negative tumors (30-32).

However, while the prognostic value of HER2 amplification/overexpression in node-positive patients has been widely demonstrated, there is no consensus on its value in node-negative cases (33-36). Although a few studies on small series have shown some prognostic impact of HER2-positivity in node-negative patients,


others, including our study of a large cohort of node-negative cases, argue against a prognostic role for HER2 in this patient subset (Figure 3) (37). Accordingly, in a recent microarray analysis to identify genes associated with poor prognosis (poor signature) and good prognosis (good signature) in node-negative patients, HER2 was not included in the 70 prognostic genes identified (38).

In any event, the prognostic impact of HER2-positivity is related only to the first 3-4 years after surgery, as indicated by the peak of early recurrences (37). The rea- sons for the early recurrences in HER2-positive tumors have been suggested to rest in events occurring at time of surgery. Indeed, growth factors released during wound-healing (39,40) have been shown to preferentially stimulate the growth of HER2-positive tumors (41). These growth factors are more likely to have a stimula- tory effect in patients with disseminated micrometastasis (node-positive patients) of an HER2-positive tumor, which might also explain the prognostic impact of HER2 according to nodal status.

Figure 3 - Hazard rate of relapse according to nodal status and HER2. A: N-, HER2-; B: N+, HER2- ; C : N+, HER2- ; D : N+, HER2+


The level of growth factors of the EGF family in post-surgical sera from breast car- cinoma patients has been shown to correlate with surgical invasiveness (42). To determine whether the growth of tumors overexpressing HER2 is affected by the extent of surgery, HER2 status of primary tumors from node-positive patients included in a randomized clinical trial addressing conservative versus invasive sur- gery was analyzed retrospectively using immunohistochemistry and the standar-


dized Herceptest. Survival analysis according to surgery indicated no differences in HER2-negative cases but an earlier onset of relapse for HER2-positive patients who underwent mastectomy in comparison to those who had conservative surgery (Figure 4). This indicates that invasive surgery can be detrimental for patients with HER2-positive breast tumors. In keeping, also early local relapses after conservative surgery were found more frequently in HER2-positive tumors, suggesting again that they are anticipated by surgery.

Figure 4 - Survival according to type of surgery and HER2-positivity



There is considerable interest in biologic markers able to predict the response of cancer patients to therapy. HER2 overexpression has been implicated as a potential indicator of responsiveness to doxorubicin. Indeed, the study by the Cancer and Acute Leukemia Group B (CALGB) of node-positive patients randomly allocated to three dose levels of CAF (cyclophosphamide, doxorubicin and fluorouracil) (43), as well as the study by Paik et al. (44) from the National Surgical Adjuvant Breast and Bowel Project (NSABP) examining the effect of doxorubicin in node-positive patients, and others (45) indicated that administration of doxorubicin was of signi- ficant benefit in HER2-positive tumors but without any beneficial effect in HER2- negative tumors.

Contrary to expectations based on most previous studies, HER2-positive tumors were recently shown to benefit from cyclophosphamide, methotrexate, and fluorouracil (CMF) treatment (46,47); however addition of doxorubicin to the CMF regimen further improved survival only in patients with HER2-positive tumors (Figure 5) (48). Also addition of taxanes provides a preferential benefit to patients with HER2-positive tumors (49). HER2-positivity has been related to endocrine therapy unresponsiveness, even in hormone receptor-positive patients (50,51). The recent observation that the level of expression of estrogen receptor is inversely correlated with HER2 expression (52), together with clinical data indica- ting that only high estrogen receptor-expressing tumors are sensitive to the anti- estrogen reagent tamoxifen (53), likely explain the tamoxifen-resistance of HER2- positive tumors. Furthermore, a cross-talk between hormones and growth factors has been identified (54,55) and the increase HER2 expression on the tumor cell

Figure 5 - survival according to adjuvant treatment and HER2-positivity. CMF+DXR ; -- CMF


membrane is observed after treatment with Tamoxifen might explain the detri- mental effect of Tamoxifen on survival of patients with HER2-positive tumor.

Surpringly, anti-aromatase treatment was found more active on HER2-positive tumors (56), indicating that the mechanism of action of this new hormone therapy as far from being fully understood.


Passive immunotherapy

Differential levels of HER2 expression in normal versus HER2-overexpressing tumor cells, together with the clear involvement of HER2 in tumor progression, make HER2 an ideal target for therapeutic approaches. The therapeutic activity of the antibody directed against HER2 (trastuzumab or Herceptin), has been evaluated as a single agent given before (57) or after (58) traditional chemotherapy, and in combination with a variety of chemotherapy agents (59), in women with HER2- overexpressing metastatic breast cancer. The results indicated a therapeutic benefit of addition of trastuzumab to the therapeutic protocol. A recent study has also shown that preoperative trastuzumab in combination with other chemotherapeutic agents was active against HER2-overexpressing early-stage breast cancer (60,61).

Thus, trastuzumab has become a standard of care for women with HER2-overex- pressing metastatic breast cancer and its clinical efficacy seems to be clear, even though cardiac toxicity when given in association with anthracyclins must be kept in mind (62,63). However the in vivo mechanism(s) of action of this reagent is not completely understood, and analyses of trastuzumab activity in experimental models have evidenced at least three different possible mechanisms: HER2 downre- gulation, antibody-dependent cell cytotoxicity (ADCC), and alteration of vessel development. In vitro treatment of HER2-overexpressing breast carcinoma cell lines with trastuzumab resulted in downmodulation of the receptor and inhibition of tumor growth (64,65). Indeed, trastuzumab induces obligate formation of HER2 homodimers, leading to an increase of ligand-mediated endocytosis of the receptor and, consequently, to significant removal of HER2 from the plasma membrane and decreased receptor-initiated constitutive signaling (65-67). In contrast, the activity of trastuzumab examined in animal models was found to depend on the engage- ment of Fc-receptor expressing lymphocytes (68), indicating ADCC as the major mechanism of antibody action. In FcRg+/+ nude mice injected subcutaneously with HER2-overexpressing human breast carcinoma cells, trastuzumab treatment resulted in near-complete (96%) inhibition of tumor growth. This protective effect was reduced more than 50% after disrupting the antibody’s ability to engage cellular Fcg receptor or in antibody-treated FcRg-/- mice. Clearly, the precise delineation of trastuzumab mechanism of action in patients is essential for the design of more suc- cessful antibody treatment protocols in breast carcinoma patients. In a pilot study on 11 patients treated with trastuzumab in neoadjuvant setting, a role of patients’lymphocytes in the clinical response was clearly underlined but larger series are required to definitively understand the mechanism of action of the antibody (69). Nevertheless, If the major mechanism is ADCC, the combination of trastu-


zumab with immunosuppressive chemotherapeutic drugs requires optimal timing of trastuzumab delivery to enable rescue of ADCC effectors such as NK cells after chemotherapy. In that context, clinical studies have demonstrated a synergistic action between trastuzumab and the drug taxane (59), which induces suppression of adaptive immunity, but selectively increases NK activity (70). To improve thera- peutic activity, stimulation of NK activity might also be considered, utilizing cyto- kines or “danger signals” such as unmethylated CpG-oligodeoxynucleotides that enhance innate immunity (71).

Active immunotherapy

Although HER2 is generally indicative of a poor prognosis, its overexpression is associated with a better outcome when inflammatory infiltrates are present in the tumor, suggesting a role for HER2 in tumor immunosurveillance (72-74). In kee- ping, development of HER2-specific antibodies has been documented in patients with primary HER2-positive tumors (75-77), and T cells reactive to HER2 were found to occur in patients with HER2-positive tumors (78), confirming the immu- nogenicity of the molecule.

HER2-derived vaccines have been used in efforts to redirect immunity to induce rejection of HER2-positive tumors (79-81). Immunization regimens of active immunotherapy have been devised that generate specific T cell responses with or without accompanying antibody responses and are currently being tested in animal models or in clinical trials (79,80,82-84).

Immunotherapeutic strategies such as immunization with MHC class I- and class II-restricted HER2-specific peptides with or without adjuvants, HER2 DNA, HER2 recombinant protein, and dendritic cells loaded with HER2 peptides are now being tested in animal models and phase I clinical trials (79,80,85,86). The vaccine preparation consisted of HER2 peptides containing putative T-helper epitopes and

Figure 6 - Incidence of mammary carcinoma in HER2-transgenic mice. ÇHER2 DNA vacci- nated-mice; <control mice


HLA-A2 binding motifs, with recombinant human GM-CSF administered as adju- vant. In the majority of immunized patients, long-lasting T cell-mediated immunity was revealed by in vitro and in vivo monitoring and, most importantly, immunity to the HER2 protein was significantly associated with epitope “spreading,” reflecting the initiation of an endogenous immune response (86).


Breast carcinoma with HER2 amplification and overexpression represents a parti- cular subset of tumors displaying a peculiar tumor progression and response to conventional and targeted therapy. The identification of HER2 is therefore manda- tory since the diagnosis of the disease in order to offer to the patient the best clinical management.

1. Yarden Y. The EGFR family and its ligands in human cancer. signalling mechanisms and therapeutic opportunities. Eur J Cancer 2001;37:S3-S8.

2. Graus-Porta D, Beerli RR, Daly JM, Hynes NE. ErbB-2, the preferred hetero- dimerization partner of all ErbB receptor, is a mediator of lateral signaling.

EMBO J 1997;16:1647-55.

3. Tzahar E, Waterman H, Chen X, Levkowitz G, Karunagaran D, Lavi S, Ratzkin BJ, Yarden Y. A hierarchinal network of interreceptor interactions determines signal transduction by neu differentiation factor/neuregulin and epidermal growth factor. Mol Cell Biol 1996;16:5276-87.

4. Threadgill DW, Dlugosz AA, Hansen LA, Tennenbaum T, Lichti U, Yee D, LaMantia C, Mourton T, Herrup K, Harris RC. Targeted disruption of mouse EGF receptor: effect of genetic background on mutant phenotype. Science 1995;269:230-4.

5. Meyer D,.Birchmeier C. Multiple essential functions of neuregulin in deve- lopment. Nature 1995;378:386-90.

6. Sibilia M, Steinbach JP, Stingl L, Aguzzi A, Wagner EF. A strain-independent postnatal neurodegeneration in mice lacking the EGF receptor. EMBO J 1998;17:719-31.

7. Gassmann M, Casagranda F, Orioli D, Simon H, Lai C, Klein R, Lemke G.

Aberrant neural and cardiac development in mice lacking the ErbB4 neure- gulin receptor. Nature 1995;378:390-4.

8. Lee K-F, Simon H, Chen H, Bates B, Hung M-C, Hauser C. Requirement for neuregulin receptor erbB2 in neural and cardiac development. Nature 1995;378:394-8.

9. Pierce JH, Arnstein P, DiMarco E, Artrip J, Kraus MH, Lonardo F, Di Fiore PP, Aaronson SA. Oncogenic potential of erbB-2 in human mammary epithelial cells. Oncogene 1991;6:1189-94.



10. Liu Y, El-Ashry D, Chen D, Ding IYF, Kern FG. MCF-7 breast cancer cells ove- rexpressing transfected c- erbB-2 have an in vitro growth advantage in estrogen- depleted conditions and reduced estrogen-dependence and tamoxifen-sensitivity in vivo. Breast Cancer Res Treat 1995;34:97-117.

11. Slamon DJ, Godolphin W, Jones LA, Holt JA, Wong SC, Keith DE, Levin WJ, Stuart SG, Udove J, Ullrich A, Press MF. Studies of the HER-2/neu proto- oncogene in human breast and ovarian cancer. Science 1989;244:707-12.

12. Zhou BP,.Hung MC. Novel targets of Akt, p21(Cipl/WAF1), and MDM2.

Semin Oncol 2002;29:62-70.

13. Di Fiore PP, Pierce JH, Kraus MH, Segatto O, King CR, Aaronson SA. erbB-2 is a potent oncogene when overexpressed in NIH/3T3 cells. Science 1987;237:178-82.

14. Muthuswamy SK, Li D, Lelievre S, Bissell MJ, Brugge JS. ErbB2, but not ErbB1, reinitiates proliferation and induces luminal repopulation in epithe- lial acini. Nat Cell Biol 2001;3:785-92.

15. Perou CM, Sorlie T, Eisen MB, van de Rijn M, Jeffrey SS, Rees CA, Pollack JR, Ross DT, Johnsen H, Akslen LA, Fluge O, Pergamenschikov A, Williams C, Zhu SX, Lonning PE, Borresen-Dale AL, Brown PO, Botstein D. Molecular portraits of human breast tumours. Nature 2000;406:747-52.

16. Sorlie T, Perou CM, Tibshirani R, Aas T, Geisler S, Johnsen H, Hastie T, Eisen MB, van de Rijn M, Jeffrey SS, Thorsen T, Quist H, Matese JC, Brown PO, Botstein D, Eystein LP, Borresen-Dale AL. Gene expression patterns of breast carcinomas distinguish tumor subclasses with clinical implications. Proc Natl Acad Sci U S A 2001;98:10869-74.

17. Bocker W, Moll R, Poremba C, Holland R, Van Diest PJ, Dervan P, Burger H, Wai D, Ina DR, Brandt B, Herbst H, Schmidt A, Lerch MM, Buchwallow IB.

Common adult stem cells in the human breast give rise to glandular and myoepithelial cell lineages: a new cell biological concept. Lab Invest 2002;82:737-46.

18. Bertucci F, Borie N, Ginestier C, Groulet A, Charafe-Jauffret E, Adelaide J, Geneix J, Bachelart L, Finetti P, Koki A, Hermitte F, Hassoun J, Debono S, Viens P, Fert V, Jacquemier J, Birnbaum D. Identification and validation of an ERBB2 gene expression signature in breast cancers. Oncogene 2004;23:2564- 75.

19. Nielsen TO, Hsu FD, Jensen K, Cheang M, Karaca G, Hu Z, Hernandez- Boussard T, Livasy C, Cowan D, Dressler L, Akslen LA, Ragaz J, Gown AM, Gilks CB, van de RM, Perou CM. Immunohistochemical and clinical charac- terization of the basal-like subtype of invasive breast carcinoma. Clin Cancer Res 2004;10:5367-74.

20. Campiglio M, Somenzi G, Olgiati C, Beretta G, Balsari A, Zaffaroni N, Valagussa P, Ménard S. Role of proliferation in HER2 status predicted res- ponse to doxorubicin. Int J Cancer 2003;105:568-73.

21. Balsari A, Casalini P, Bufalino R, Berrino F, Ménard S. Role of hormonal risk factors in HER2-positive breast carcinomas. Br J Cancer 2003;88:1032-4.


22. Gancberg D, Jarvinen T, Di Leo A, Rouas G, Cardoso F, Paesmans M, Verhest A, Piccart MJ, Isola J, Larsimont D. Evaluation of HER-2/NEU protein expression in breast cancer by immunohistochemistry: an interlaboratory study assessing the reproducibility of HER-2/NEU testing. Breast Cancer Res Treat 2002;74:113-20.

23. Rhodes A, Jasani B, Anderson E, Dodson AR, Balaton AJ. Evaluation of HER- 2/neu immunohistochemical assay sensitivity and scoring on formalin-fixed and paraffin-processed cell lines and breast tumors: a comparative study involving results from laboratories in 21 countries. Am J Clin Pathol 2002;118:408-17.

24. Paik S, Bryant J, Tan-Chiu E, Romond E, Hiller W, Park K, Brown A, Yothers G, Anderson S, Smith R, Wickerham DL, Wolmark N. Real-world perfor- mance of HER2 testing-national surgical adjuvant breast and bowel project experience. J Natl Cancer Inst 2002;94:852-4.

25. Lal P, Salazar PA, Hudis CA, Ladanyi M, Chen B. HER-2 testing in breast cancer using immunohistochemical analysis and fluorescence in situ hybridi- zation: a single-institution experience of 2,279 cases and comparison of dual- color and single-color scoring. Am J Clin Pathol 2004;121:631-6.

26. Cell Markers and Cytogenetics Committees College of American Pathologists. Clinical laboratory assays for HER-2/neu amplification and overexpression: quality assurance, standardization, and proficiency testing.

Arch Pathol Lab Med 2002;126:803-8.

27. Roche PC, Suman VJ, Jenkins RB, Davidson NE, Martino S, Kaufman PA, Addo FK, Murphy B, Ingle JN, Perez EA. Concordance between local and cen- tral laboratory HER2 testing in the breast intergroup trial N9831. J Natl Cancer Inst 2002;94:855-7.

28. Winston JS, Ramanaryanan J, Levine E. HER-2/neu evaluation in breast cancer are we there yet? Am J Clin Pathol 2004;121:S33-S49.

29. Meng S, Tripathy D, Shete S, Ashfaq R, Haley B, Perkins S, Beitsch P, Khan A, Euhus D, Osborne C, Frenkel E, Hoover S, Leitch M, Clifford E, Vitetta E, Morrison L, Herlyn D, Terstappen LW, Fleming T, Fehm T, Tucker T, Lane N, Wang J, Uhr J. HER-2 gene amplification can be acquired as breast cancer progresses. Proc Natl Acad Sci U S A 2004;101:9393-8.

30. Ménard S, Forti S, Castiglioni F, Agresti R, Balsari A. HER2 as a prognostic factor in breast cancer. Oncology 2001;61:67-72.

31. Masood S,.Bui MM. Prognostic and predictive value of HER2/neu oncogene in breast cancer. Microsc Res Tech 2002;59:102-8.

32. Ménard S, Tagliabue E, Campiglio M, Pupa SM. Role of HER2 gene overex- pression in breast carcinoma. J Cell Physiol 2000;182:150-62.

33. Press MF, Bernstein L, Thomas PA, Meisner LF, Zhou JY, Ma YL, Hung G, Robinson RA, Harris C, El-Naggar A, Slamon DJ, Phillips RN, Ross JS, Wolman SR, Flom KJ. HER-2/neu gene amplification characterized by fluo- rescence in situ hybridization: Poor prognosis in node-negative breast carci- nomas. J Clin Oncol 1997;15:2894-904.


34. Cooke T, Reeves J, Lannigan A, Stanton P. The value of the human epidermal growth factor receptor-2 (HER2) as a prognostic marker. Eur J Cancer 2001;37:3-10.

35. Volpi A, De Paola F, Nanni O, Granato AM, Bajorko P, Becciolini A, Scarpi E, Riccobon A, Balzi M, Amadori D. Prognostic significance of biologic markers in node-negative breast cancer patients: a prospective study. Breast Cancer Res Treat 2000;63:181-92.

36. Ross JS, Muraca PJ, Jaffe D. Multivariate analysis of prognostic factors in lymph node negative breast cancer. Mod Pathol 1998;11:26a.

37. Ménard S, Balsari A, Casalini P, Tagliabue E, Campiglio M, Bufalino R, Cascinelli N. HER2-positive breast carcinomas as a particular subset with peculiar clinical behaviors. Clin Cancer Res 2002;8:520-5.

38. Van'T Veer LJ, Dai H, Van de Vijver MJ, He YD, Hart AA, Mao M, Peterse HL, van der Kooy K, Marton MJ, Witteveen AT, Schreiber GJ, Kerkhoven RM, Roberts C, Linsley PS, Bernards R, Friend SH. Gene expression profiling pre- dicts clinical outcome of breast cancer. Nature 2002;415:530-6.

39. Murthy SM, Goldschmidt RA, Rao LN, Ammirati M, Buchmann T, Scanlon EF. The influence of surgical trauma on experimental metastasis. Cancer 1989;64:2035-44.

40. Sieweke MH,.Bissell MJ. The tumor-promoting effect of wounding: a pos- sible role for TGF-beta-induced stromal alterations. Crit Rev Oncog 1994;5:297-311.

41. Tagliabue E, Agresti R, Ghirelli C, Morelli D, Ménard S. Letter to the editor.

The early relapse of premenopausal patients after surgery for node-positive breast carcinoma. Breast Cancer Res Treat 2001;70:155-6.

42. Tagliabue E, Agresti R, Carcangiu ML, Ghirelli C, Morelli D, Campiglio M, Martel M, Giovanazzi R, Greco M, Balsari A, Ménard S. Role of HER2 in wound-induced breast carcinoma proliferation. Lancet 2003;362:527-33.

43. Thor AD, Berry DA, Budman DR, Muss HB, Kute T, Henderson IC, Barcos M, Cirrincione C, Edgerton S, Allred C, Norton L, Liu ET. erbB-2, p53, and effi- cacy of adjuvant therapy in lymph node- positive breast cancer. J Natl Cancer Inst 1998;90:1346-60.

44. Paik SM, Bryant J, Park CH, Fisher B, Tan-Chiu E, Hyams D, Fisher ER, Lippman ME, Wickerham DL, Wolmark N. erbB-2 and response to doxoru- bicin in patients with axillary lymph node-positive, hormone receptor-nega- tive breast cancer. J Natl Cancer Inst 1998;90:1361-70.

45. Di Leo A, Gancberg D, Larsimont D, Tanner M, Jarvinen T, Rouas G, Dolci S, Leroy JY, Paesmans M, Isola J, Piccart MJ. HER-2 amplification and topoiso- merase IIalpha gene aberrations as predictive markers in node-positive breast cancer patients randomly treated either with an anthracycline-based therapy or with cyclophosphamide, methotrexate, and 5-fluorouracil. Clin Cancer Res 2002;8:1107-16.

46. Ozinsky A, Underhill DM, Fontenot JD, Hajjar AM, Smith KD, Wilson CB, Schroeder L, Aderem A. The repertoire for pattern recognition of pathogens


by the innate immune system is defined by cooperation between toll-like receptors. Proc Natl Acad Sci U S A 2000;97:13766-71.

47. Ménard S, Valagussa P, Pilotti S, Gianni L, Biganzoli E, Boracchi P, Tomasic G, Casalini P, Marubini E, Colnaghi MI, Cascinelli N, Bonadonna G. Response to Cyclophosphamide, Methotrexate, and Fluorouracil in lymph node-posi- tive breast cancer according to HER2 overexpression and other tumor bio- logic variables. J Clin Oncol 2001;19:329-35.

48. Moliterni A, Ménard S, Valagussa P, Biganzoli E, Boracchi P, Balsari A, Casalini P, Tomasic G, Marubini E, Pilotti S, Bonadonna G. HER2 overexpres- sion and doxorubicin in the adjuvant chemotherapy of resectable breast cancer. J Clin Oncol 2003;21:458-62.

49. Konecny GE, Thomssen C, Luck HJ, Untch M, Wang HJ, Kuhn W, Eidtmann H, du BA, Olbricht S, Steinfeld D, Mobus V, Von Minckwitz G, Dandekar S, Ramos L, Pauletti G, Pegram MD, Janicke F, Slamon DJ. Her-2/neu gene amplification and response to paclitaxel in patients with metastatic breast cancer. J Natl Cancer Inst 2004;96:1141-51.

50. Grunt TW, Saceda M, Martin MB, Lupu R, Dittrich E, Krupitza G, Harant H, Huber H, Dittrich C. Bidirectional interactions between the estrogen receptor and the c-erbB-2 signaling pathways: Heregulin inhibits estrogenic effects in breast cancer cells. Int J Cancer 1995;63:560-7.

51. Elledge RM, Green S, Ciocca D, Pugh R, Allred DC, Clark GM, Hill J, Ravdin P, O'Sullivan J, Martino S, Osborne CK. HER-2 expression and response to tamoxifen in estrogen receptor-positive breast cancer: a southwest oncologty group study. Clin Cancer Res 1998;4:7-12.

52. Konecny G, Pauletti G, Pegram M, Untch M, Dandekar S, Aguilar Z, Wilson C, Rong HM, Bauerfeind I, Felber M, Wang HJ, Beryt M, Seshadri R, Hepp H, Slamon DJ. Quantitative association between HER-2/neu and steroid hor- mone receptors in hormone receptor-positive primary breast cancer. J Natl Cancer Inst 2003;95:142-53.

53. Early Breast Cancer Trialists' Collaborative Group. Tamoxifen for early breast cancer: an overview of the randomised trials. Lancet 1998;351:1451-67.

54. Yang Z, Barnes CJ, Kumar R. Human epidermal growth factor receptor 2 status modulates subcellular localization of and interaction with estrogen receptor alpha in breast cancer cells. Clin Cancer Res 2004;10:3621-8.

55. Johnston SR, Head J, Pancholi S, Detre S, Martin LA, Smith IE, Dowsett M.

Integration of signal transduction inhibitors with endocrine therapy: an approach to overcoming hormone resistance in breast cancer. Clin Cancer Res 2003;9:524S-32S.

56. Ellis MJ, Coop A, Singh B, Mauriac L, Llombert-Cussac A, Janicke F, Miller WR, Evans DB, Dugan M, Brady C, Quebe-Fehling E, Borgs M. Letrozole is more effective neoadjuvant endocrine therapy than tamoxifen for ErbB-1- and/or ErbB-2-positive, estrogen receptor-positive primary breast cancer:

evidence from a phase III randomized trial. J Clin Oncol 2001;19:3808-16.

57. Vogel CL, Cobleigh MA, Tripathy D, Gutheil JC, Harris LN, Fehrenbacher L, Slamon DJ, Murphy M, Novotny WF, Burchmore M, Shak S, Stewart SJ, Press


M. Efficacy and safety of trastuzumab as a single agent in first-line treatment of HER2-overexpressing metastatic breast cancer. J Clin Oncol 2002;20:719- 26.

58. Cobleigh MA, Vogel CL, Tripathy D, Robert NJ, Scholl S, Fehrenbacher L, Wolter JM, Paton V, Shak S, Lieberman G, Slamon DJ. Multinational study of the efficacy and safety of humanized anti-HER2 monoclonal antibody in women who have HER2-overexpressing metastatic breast cancer that has progressed after chemotherapy for metastatic disease. J Clin Oncol 1999;17:2639-48.

59. Slamon DJ, Leyland-Jones B, Shak S, Fuchs H, Paton V, Bajamonde A, Fleming T, Eiermann W, Wolter J, Pegram M, Baselga J, Norton L. Use of che- motherapy plus a monoclonal antibody against HER2 for metastatic breast cancer that overexpresses HER2. N Engl J Med 2001;344:783-92.

60. Burstein HJ, Harris LN, Gelman R, Lester SC, Nunes RA, Kaelin CM, Parker LM, Ellisen LW, Kuter I, Gadd MA, Christian RL, Kennedy PR, Borges VF, Bunnell CA, Younger J, Smith BL, Winer EP. Preoperative therapy with tras- tuzumab and paclitaxel followed by sequential adjuvant doxorubicin/cyclo- phosphamide for HER2 overexpressing stage II or III breast cancer: a pilot study. J Clin Oncol 2003;21:46-53.

61. Tedesco KL, Thor AD, Johnson DH, Shyr Y, Blum KA, Goldstein LJ, Gradishar WJ, Nicholson BP, Merkel DE, Murrey D, Edgerton S, Sledge GW, Jr.

Docetaxel combined with trastuzumab is an active regimen in HER-2 3+ ove- rexpressing and fluorescent in situ hybridization-positive metastatic breast cancer: a multi-institutional phase II trial. J Clin Oncol 2004;22:1071-7.

62. Perez EA,.Rodeheffer R. Clinical cardiac tolerability of trastuzumab. J Clin Oncol 2004;22:322-9.

63. Garratt AN, Ozcelik C, Birchmeier C. ErbB2 pathways in heart and neural diseases. Trends Cardiovasc Med 2003;13:80-6.

64. Hieken TJ, Mehta RR, Shilkaitis A. HER-2/neu and p53 expression in breast cancer: valid prognostic markers when assessed by direct immunoassay, but not by immunohistochemistry. Proc Annu Meet Am Soc Clin Oncol 1996;15:113.

65. Hudziak RM, Lewis GD, Winget M, Fendly BM, Shepard HM, Ullrich A.

p185HER2 monoclonal antibody has antiproliferative effects in vitro and sensitizes human breast tumor cells to tumor necrosis factor. Mol Cell Biol 1989;9:1165-72.

66. Sarup JC, Johnson RM, King KL, Fendly BM, Lipari MT, Napier MA, Ullrich A, Shepard HM. Characterization of an anti-p185HER2 monoclonal anti- body that stimulates receptor function and inhibits tumor cell growth.

Growth Regul 1991;1:72-82.

67. De Santes K, Slamon D, Anderson SK, Shepard M, Fendly B, Maneval D, Press O. Radiolabeled antibody targeting of the HER-2/neu oncoprotein. Cancer Res 1992;52:1916-23.

68. Clynes RA, Towers TL, Presta LG, Ravetch JV. Inhibitory Fc receptors modu- late in vivo cytoxicity against tumor targets. Nat Med 2000;6:443-6.


69. Gennari R, Ménard S, Fagnoni F, Ponchio L, Scelsi M, Tagliabue E, Castiglioni F, Villani L, Magalotti C, Gibelli N, Oliviero B, Ballardini B, Da Prada G, Zambelli A, Costa A. Pilot study of the mechanism of action of preoperative trastuzumab in patients with primary operable breast tumors overexpressing HER2. Clin Cancer Res 2004;10:5650-5.

70. Tsavaris N, Kosmas C, Vadiaka M, Kanelopoulos P, Boulamatsis D. Immune changes in patients with advanced breast cancer undergoing chemotherapy with taxanes. Br J Cancer 2002;87:21-7.

71. Sfondrini L, Besusso D, Rumio C, Rodolfo M, Ménard S, Balsari A.

Prevention of spontaneous mammary adenocarcinoma in HER-2/neu trans- genic mice by foreign DNA. FASEB J 2002;16:1749-54.

72. Ménard S, Pupa SM, Casalini P, Rilke F, Colnaghi MI. Relationship of histo- logical grade, c-erbB-2 expression and inflammatory infiltrate to prognosis in carcinoma of the breast - In reply. J Clin Oncol 1996;14:2407.

73. Rilke F, Colnaghi MI, Cascinelli N, Andreola S, Baldini MT, Bufalino R, Della Porta G, Ménard S, Pierotti MA, Testori A. Prognostic significance of HER- 2/neu expression in breast cancer and its relationship to other prognostic fac- tors. Int J Cancer 1991;49:44-9.

74. Pupa SM, Bufalino R, Invernizzi AM, Andreola S, Rilke F, Lombardi L, Colnaghi MI, Ménard S. Macrophage infiltrate and prognosis in c-erbB-2- overexpressing breast carcinomas. J Clin Oncol 1996;14:85-94.

75. Disis ML, Pupa SM, Gralow JR, Dittadi R, Ménard S, Cheever MA. High titer HER-2/neu protein specific antibody immunity can be detected in patients with early stage breast cancer. J Clin Oncol 1997;15:3363-7.

76. Pupa SM, Ménard S, Andreola S, Colnaghi MI. Antibody response against the c-erbB-2 oncoprotein in breast carcinoma patients. Cancer Res 1993;53:5864-6.

77. Disis ML, Calenoff E, McLaughlin G, Murphy AE, Chen W, Groner B, Jeschke M, Lydon N, McGlynn E, Livingston RB, Moe R, Cheever MA. Existent T-cell and antibody immunity to HER-2/neu protein in patients with breast cancer.

Cancer Res 1994;54:16-20.

78. Disis ML,.Cheever MA. HER-2/neu protein: a target for antigen-specific immunotherapy of human cancer. Adv Cancer Res 1997;71:343-71.

79. Foy TM, Fanger GR, Hand S, Gerard C, Bruck C, Cheever MA. Designing HER2 vaccines. Semin Oncol 2002;29:53-61.

80. Kiessling R, Weil WZ, Herrmann F, Lindencrona JA, Choudhury A, Kono K, Seliger B. Cellular immunity to the Her-2/neu protooncogene. Adv Cancer Res 2002;85:101-44.

81. Piechocki MP, Ho YS, Pilon S, Wei WZ. Human ErbB-2 (Her-2) transgenic mice: a model system for testing Her-2 based vaccines. J Immunol 2003;171:5787-94.

82. Rovero S, Amici A, Carlo ED, Bei R, Nanni P, Quaglino E, Porcedda P, Boggio K, Smorlesi A, Lollini PL, Landuzzi L, Colombo MP, Giovarelli M, Musiani P, Forni G. DNA vaccination against rat her-2/Neu p185 more effectively inhi-


bits carcinogenesis than transplantable carcinomas in transgenic BALB/c mice. J Immunol 2000;165:5133-42.

83. Di Carlo E, Rovero S, Boggio K, Quaglino E, Amici A, Smorlesi A, Forni G, Musiani P. Inhibition of mammary carcinogenesis by systemic interleukin 12 or p185neu DNA vaccination in Her-2/neu transgenic BALB/c mice. Clin Cancer Res 2001;7:830s-7s.

84. Nanni P, Nicoletti G, De Giovanni C, Landuzzi L, Di Carlo E, Cavallo F, Pupa SM, Rossi I, Colombo MP, Ricci C, Astolfi A, Musiani P, Forni G, Lollini P-L.

Combined allogeneic tumor cell vaccination and systemic interleukin 12 pre- vents mammary carcinogenesis in HER-2/neu transgenic mice. J Exp Med 2001;194:1-12.

85. Knutson KL, Schiffman K, Disis ML. Immunization with a HER-2/neu helper peptide vaccine generates HER-2/neu CD8 T-cell immunity in cancer patients. J Clin Invest 2001;107:477-84.

86. Disis ML, Gooley TA, Rinn K, Davis D, Piepkorn M, Cheever MA, Knutson KL, Schiffman K. Generation of T-cell immunity to the HER-2/neu protein after active immunization with HER-2/neu peptide-based vaccines. J Clin Oncol 2002;20:2624-32.


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