title: Mitosis in circulating tumor cells stratifies highly aggressive breast carcinomas.
abstract: Enumeration of circulating tumor cells (CTCs) isolated from the peripheral blood of breast cancer patients holds promise as a clinically relevant, minimally invasive diagnostic test. However, CTC utility has been limited as a prognostic indicator of survival by the inability to stratify patients beyond general enumeration. In comparison, histological biopsy examinations remain the standard method for confirming malignancy and grading malignant cells, allowing for cancer identification and then assessing patient cohorts for prognostic and predictive value. Typically, CTC identification relies on immunofluorescent staining assessed as absent/present, which is somewhat subjective and limited in its ability to characterize these cells. In contrast, the physical features used in histological cytology comprise the gold standard method used to identify and preliminarily characterize the cancer cells. Here, we superimpose the methods, cytologically subtyping CTCs labeled with immunohistochemical fluorescence stains to improve their prognostic value in relation to survival.
  
  
  
  In this single-blind prospective pilot study, we tracked 36 patients with late-stage breast cancer over 24 months to compare overall survival between simple CTC enumeration and subtyping mitotic CTCs. A power analysis (1-β = 0. 9, α = 0.05) determined that a pilot size of 30 patients was sufficient to stratify this patient cohort; 36 in total were enrolled.
  
  
  
  Our results confirmed that CTC number is a prognostic indicator of patient survival, with a hazard ratio 5.2, p = 0.005 (95 % CI 1.6-16.5). However, by simply subtyping the same population based on CTCs in cytological mitosis, the hazard ratio increased dramatically to 11.1, p < 0.001 (95 % CI 3.1-39.7).
  
  
  
  Our data suggest that (1) mitotic CTCs are relativity common in aggressive late-stage breast cancer, (2) mitotic CTCs may significantly correlate with shortened overall survival, and (3) larger and more defined patient cohort studies are clearly called for based on this initial pilot study.
authors.affiliation: Creatv MicroTech, Inc., 11 Deer Park Dr., Monmouth Junction, NJ, 08852, USA. dan@creatvmicrotech.com.
authors.forename: Daniel L
authors.initials: DL
authors.lastname: Adams
authors.affiliation: Rutgers, the State University of New Jersey, 71 Dudley Rd, New Brunswick, NJ, 08901, USA.
authors.forename: Diane K
authors.initials: DK
authors.lastname: Adams
authors.affiliation: HeMemics Biotechnologies Inc., 9700 Great Seneca Highway, Rockville, MD, 20850, USA.
authors.forename: Steingrimur
authors.initials: S
authors.lastname: Stefansson
authors.affiliation: George Washington University Medical Center, 2121 Eye Street, NW, Washington, DC, 20052, USA.
authors.forename: Christian
authors.initials: C
authors.lastname: Haudenschild
authors.affiliation: University of Maryland Baltimore Greenebaum Cancer Center, 655 W. Baltimore St., Baltimore, MD, 21136, USA.
authors.forename: Stuart S
authors.initials: SS
authors.lastname: Martin
authors.affiliation: University of Maryland Baltimore Greenebaum Cancer Center, 655 W. Baltimore St., Baltimore, MD, 21136, USA.
authors.forename: Monica
authors.initials: M
authors.lastname: Charpentier
authors.affiliation: University of Maryland Baltimore Greenebaum Cancer Center, 655 W. Baltimore St., Baltimore, MD, 21136, USA.|Mayo Clinic Cancer Center, 4500 San Pablo Rd., Jacksonville, FL, 32224, USA.
authors.forename: Saranya
authors.initials: S
authors.lastname: Chumsri
authors.affiliation: Robert H Lurie Comprehensive Cancer Center, Northwestern University, 645 N Michigan Avenue, Chicago, IL, 60611, USA.
authors.forename: Massimo
authors.initials: M
authors.lastname: Cristofanilli
authors.affiliation: Creatv MicroTech, Inc., 11609 Lake Potomac Drive, Potomac, MD, 20854, USA.
authors.forename: Cha-Mei
authors.initials: CM
authors.lastname: Tang
authors.affiliation: Fox Chase Cancer Center, Protocol Support Laboratory, 333 Cottman Ave., Philadelphia, PA, 19111, USA.
authors.forename: R Katherine
authors.initials: RK
authors.lastname: Alpaugh
mesh_terms: D000328:Adult; D000368:Aged; D014408:Biomarkers, Tumor; D001943:Breast Neoplasms / Q000401:mortality / Q000473:pathology*; D018450:Disease Progression; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008875:Middle Aged; D008938:Mitosis; D060787:Neoplasm Grading; D009367:Neoplasm Staging; D009360:Neoplastic Cells, Circulating / Q000473:pathology*; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies
chemical_list: D014408:Biomarkers, Tumor
keywords: Blood based biopsy; Breast cancer cell motility; Circulating tumor cells; Mitotic index of CTCs