title: A novel method for downstream characterization of breast cancer circulating tumor cells following CellSearch isolation.
abstract: BACKGROUND
  Enumeration of circulating tumor cells (CTCs) obtained from minimally invasive blood samples has been well established as a valuable monitoring tool in metastatic and early breast cancer, as well as in several other cancer types. The gold standard technology for detecting CTCs in blood against a backdrop of millions of leukocytes is the FDA-approved CellSearch system (Janssen Diagnostics), which relies on EpCAM-based immunomagnetic separation. Secondary characterization of these cells could enable treatment selection based on specific targets in these cells, as well as providing a real time window into the metastatic process and offering unique insights into tumor heterogeneity. The objective of this study was to develop a method for downstream characterization of CTCs following isolation with the CellSearch system.
  
  
  METHODS
  An in vitro CTC model system focusing on clinically useful treatment predictive biomarkers in breast cancer, specifically the estrogen receptor α (ERα) and the human epidermal growth factor receptor 2 (HER2), was established using healthy donor blood spiked with breast cancer cell lines MCF7 (ERα(+)/HER2(-)) and SKBr3 (ERα(-)/HER2(+)). Following CTC isolation by CellSearch, the captured CTCs were further enriched and fixed on a microscope slide using the in-house-developed CTC-DropMount technique.
  
  
  RESULTS
  The recovery rate of CTCs after CellSearch Profile analysis and CTC-DropMount was 87%. A selective and consistent triple-immunostaining protocol was optimized. Cells positive for DAPI, cytokeratin (CK) 8, 18 and 19, but negative for the leukocyte-specific marker CD45, were classified as CTCs and subsequently analyzed for ERα and HER2 expression. The method was verified in breast cancer patient samples, thus demonstrating its clinical relevance.
  
  
  CONCLUSIONS
  Our results show that it is possible to ascertain the status of important predictive biomarkers expressed in breast cancer CTCs using the newly developed CTC-DropMount technique. Downstream characterization of multiple biomarkers using a standard fluorescence microscope demonstrates that important clinical and biological information may be obtained from a single patient blood sample following either CellSearch epithelial or profile analyses.
  
  
  BACKGROUND
  Clinical Trials NCT01322893.
authors.affiliation: Division of Oncology and Pathology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden. henrik.frithiof@med.lu.se.
authors.forename: Henrik
authors.initials: H
authors.lastname: Frithiof
authors.affiliation: Division of Oncology and Pathology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden. charlotte.welinder@med.lu.se.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Welinder
authors.affiliation: Division of Oncology and Pathology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden. anna-maria.larsson@med.lu.se.|Skåne Department of Oncology, Skåne University Hospital, Lund, Sweden. anna-maria.larsson@med.lu.se.
authors.forename: Anna-Maria
authors.initials: AM
authors.lastname: Larsson
authors.affiliation: Division of Surgery, Department of Clinical Sciences, Lund University, Lund, Sweden. lisa.ryden@med.lu.se.|Department of Surgery, Skåne University Hospital, Lund, Sweden. lisa.ryden@med.lu.se.
authors.forename: Lisa
authors.initials: L
authors.lastname: Rydén
authors.affiliation: Division of Oncology and Pathology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden. kristina.aaltonen@med.lu.se.
authors.forename: Kristina
authors.initials: K
authors.lastname: Aaltonen
mesh_terms: D001943:Breast Neoplasms / Q000097:blood / Q000473:pathology*; D045744:Cell Line, Tumor; D002469:Cell Separation / Q000379:methods*; D047628:Estrogen Receptor alpha / Q000378:metabolism; D005260:Female; D005455:Fluorescent Antibody Technique; D006801:Humans; D017493:Leukocyte Common Antigens / Q000378:metabolism; D009362:Neoplasm Metastasis; D009360:Neoplastic Cells, Circulating / Q000473:pathology*; D018719:Erb-b2 Receptor Tyrosine Kinases / Q000378:metabolism; D015203:Reproducibility of Results; D014019:Tissue Donors
chemical_list: D047628:Estrogen Receptor alpha; D017493:Leukocyte Common Antigens; D018719:Erb-b2 Receptor Tyrosine Kinases; C508053:ERBB2 protein, human