Thus TACS-3 is a potential marker of a highly invasive tumor, in which the reorganization of the matrix around the tumor apparently reflects a dramatic increase in the ability to spread and metastasize. The results by Conklin et al provide the first retrospective test of this hypothesis using a tissue microarray of 207 breast cancer patients with median clinical follow-up of 6 years. We will focus here on the most successful scoring method, termed Score 1. After each tissue core was divided into 14 areas, the presence of TACS-3 structures was scored separately by three pathologists. A receiver operating curve analysis determined the optimum threshold and demonstrated that detection of only one or two TACS-3 structures in a tissue core was sufficient.
In univariate analysis, TACS-3 scoring showed a significant association with both disease-specific survival and disease-free interval, each with a hazard ratio of 3. To test whether the TACS-3 scoring might provide a novel independent biomarker, the authors then performed a multivariate analysis. A wide range of markers were evaluated including tumor grade, size, patient age, estrogen receptor, progesterone receptor (PR), HER-2, and node status, among others. Within this group, TACS-3 was an independent prognostic marker for both disease-specific survival and disease-free interval, together with PR, ER, node status, and tumor size. Notably, TACS-3 did not correlate with any other markers tested in the analysis. Given these promising results, a classification and regression tree analysis was then performed for predicting 10-year disease-specific survival. Importantly, the TACS-3 score provided valuable prognostic information for patients with large ER-positive tumors. Patients with TACS-3-positive tumors showed a 40% reduction in survival compared with those who had TACS-3-negative tumors.
The TACS-3 scoring shows significant correlation with survival in an important category of breast cancer patients—those with ER-positive tumors that are >1.35 cm. The challenge is to translate this correlation to the pathology laboratory. The use of multiphoton microscopy for research studies of human cancer tissues, including freshly biopsied tissues, has been reported by a number of groups. Our opinion is that this practice is currently impractical for standard histopathology laboratories because of the expense of multiphoton microscopes and the amount of time required for the analysis. However, with the development of inexpensive laser sources, multiphoton microscopy may be accessible in the future. In considering less expensive substitutes, it is not exactly clear how TACS-3 signals detected by multiphoton microscopy correspond to standard histopathology, but there are several options for analyzing stroma. These options include selective demonstration of collagen fibers by Sirius red or reticulum stains or visualization along with cellular detail in H&E and trichrome stains.
Final Reflections
We suggest that two distinct processes exist: TACS-2 reflects stromal formation and organization controlled by the tumor cells, an orderly phase of growth and maturation that follows initial stromal penetration by tumor cells. In contrast, TACS-3 reflects invasion and disruption of preformed stroma by tumor cells. It therefore seems essential to define the histologic correlates of the two-photon TACS-3 detection so that the signatures can be assessed within a standard pathology work-up. The data by Conklin et al1 also imply a correlation with stromal expression of syndecan-1, a cell surface receptor that links extracellular matrix and cytoskeleton. Their description is a bit confusing, because an earlier article from this group characterized tumor cell expression of syndecan-1.18 The localization of syndecan-1 thus requires clarification, because immunohistochemical detection of syndecan-1 could prove to be an easily detected surrogate of TACS-3.
In summary, Conklin et al1 provide an admirable example of studies that bridge mouse cancer models and human diagnostic pathology. However, application of TACS-3 as a histologic or prognostic biomarker requires translation into parameters that fit into the routine pathology work-up. From a biological perspective, TACS-3 may represent a specific type of matrix organization controlled by tumor cells or a result of aggressive invasion. These alternatives define a valuable investigation into fundamental mechanisms of tumor progression.