Research ArticleClinical Studies
Open Access

Identifying High Recurrence Risk in Breast Carcinoma Patients Through Spatial Transcriptomic Analysis

JINAH CHU, SUNG-IM DO and HYUN-SOO KIM
Anticancer Research October 2024, 44 (10) 4387-4401; DOI: https://doi.org/10.21873/anticanres.17268

Abstract

Background/Aim: Comparing gene expression profiles according to recurrence risk using spatially resolved transcriptomic analysis has not been reported. This study aimed to identify distinct genetic features of breast carcinoma associated with a high Oncotype DX Recurrence Score (ORS). Patients and Methods: Patients were categorized into two groups, ORS-high (ORS-H; two patients) and ORS-non-high (ORS-NH; five patients). We performed digital spatial profiling and bioinformatic analyses to investigate the spatial transcriptomic profiles. Results: Lysozyme (LYZ), complement C1q C chain (C1QC), and complement C1q B chain (C1QB) exhibited the highest fold changes in the stromal compartment of the ORS-H group. Gene ontology enrichment analysis of the ORS-H group revealed significant up-regulation of genes associated with immune response in the stromal compartment, including lymphocyte-mediated immunity, adaptive immune response related to the immunoglobulin superfamily, and leukocyte-mediated immunity. Gene set enrichment analysis showed significant positive enrichment of gene sets associated with interferon (IFN) response and complement pathways in the stromal compartment. Conclusion: This study highlights significant differences in gene expression profiles and spatially resolved transcriptional activities between ORS-H and ORS-NH breast carcinomas. The significant up-regulation of genes and pathways associated with cell-mediated immunity, IFN response, and complement C1q in the stromal compartment of the ORS-H group warrants further evaluation with larger population cohorts.

Key Words:

Breast carcinoma is the most commonly diagnosed malignancy in women, with 2.3 million cases in 2020, which is projected to rise to 3.2 million by 2040 (1, 2). This underscores the urgent need for innovative therapeutic strategies. Early-stage breast carcinoma, where the tumor is confined to the breast with or without axillary lymph node metastasis, has a favorable prognosis with a 5-year survival rate of up to 90% (3, 4). In contrast, advanced or metastatic breast carcinoma is often incurable with standard treatments, which primarily aim to delay progression and provide palliative care. Early detection of breast carcinoma significantly enhances the likelihood of successful treatment (5-8). Simultaneously, to reduce carcinoma-related mortality, it is crucial to identify women at a high risk of recurrence or metastasis. Understanding the interplay of breast carcinoma risk factors has led to the development of risk stratification models that integrate molecular data into clinical practice (9, 10).

Despite advancements in risk prediction methodologies, a considerable gap remains in our ability to assess the intratumoral heterogeneity of breast carcinoma. This heterogeneity is evident at the morphological and molecular levels, with gene expression patterns and interactions between tumor cells and stromal populations varying widely (11, 12). Traditional diagnostic methods often lose spatial information critical for understanding the tumor microenvironment, which is a key determinant of tumor progression and treatment response (9). Digital spatial profiling (DSP) preserves this spatial context, revealing how different regions of the same tumor may exhibit distinct gene expression patterns and respond differently to treatments. This technique enhances our understanding of tumor development and progression and is crucial for personalizing treatment strategies (11).

DSP quantifies RNA transcripts using barcoded DNA oligonucleotides attached to in situ hybridization probes via an ultraviolet (UV)-photocleavable linker (13). Regions of interest (ROIs) are exposed to UV light, cleaving the linker and releasing the barcoded oligonucleotides for capture (14). This spatially resolved RNA detection enables transcriptomic characterization in distinct tumor areas. DSP allows for multiplexed, quantitative RNA profiling, efficiently extracting rich data from small biopsy samples, minimizing the need for additional invasive procedures, and reducing patient discomfort and healthcare costs (11). Currently, although DSP is primarily used in research, it is increasingly being applied in clinical studies (15). In some cases, DSP is used to test exploratory endpoints in clinical trials (11). Implementing DSP in clinical practice requires specialized expertise and training for healthcare professionals. Effective DSP use necessitates a thorough understanding of the technology, its principles, and the interpretation of its results (9).

Several spatially resolved transcriptomic studies have been recently reported in breast carcinoma (16-19), but none have documented differences in gene expression profiles between patients at a high risk of recurrence and those who are not. This study aimed to identify distinct genetic characteristics of breast carcinoma associated with high recurrence risk using DSP and the Oncotype DX (ODX) Recurrence Score (ORS). ODX is a 21-gene recurrence score assay used to estimate the likelihood of breast carcinoma recurrence and benefit of chemotherapy (20, 21). Our findings would be particularly beneficial for clarifying the molecular features linked to a high risk of recurrence in patients with breast carcinoma.

Patients and Methods

Case selection and data collection. The study protocol was approved by the Institutional Review Board of Kangbuk Samsung Hospital (protocol number: 2024-06-031; date of approval: June 28, 2024). Given the retrospective nature of this study, the requirement for signed informed consent was waived. Between October 2016 and June 2022, we identified seven patients with estrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative breast carcinoma. Patients were divided into the following two groups: ORS-non-high (ORS-NH; ORS <26) and ORS-high (ORS-H; ORS ≥26), following the National Comprehensive Cancer Network Guidelines (22). Two board-certified pathologists examined all available hematoxylin and eosin (H&E)-stained slides to confirm the diagnosis. We reviewed electronic medical records to collect information on age at diagnosis, histological type and grade, tumor size, lymph node metastasis, Allred scores for hormone receptor expression (23-25), HER2 expression, and Ki-67 labeling index (24, 25). The numerical ORS, ranging from 0 to 100, was calculated based on the ODX formula (26), with the highest weight assigned to genes related to proliferation, HER2, and sex hormones (27).

Tissue microarray (TMA) technique. TMA blocks were constructed as described previously (24, 25). The two most representative tumor areas were marked on all H&E-stained slides and the corresponding formalin-fixed, paraffin-embedded tissue blocks. Two 3-mm diameter tissue cores were taken from marked areas in each tissue block and manually assembled into recipient TMA blocks, ensuring each core contained ≥70% of the tumor volume. Recipient blocks had holes created at 2-mm intervals using an X-Y position guide. Tissue cores were transferred into these holes, and a pair of TMA blocks was constructed for each case.

DSP technique. We profiled 4-mm thick tissue sections from the TMA blocks using the Technology Access Program (NanoString Technologies, Seattle, WA, USA). Circular ROIs in each tissue core were selected based on two visualization markers, pan-cytokeratin (CK) and smooth muscle actin (SMA), representing the epithelial and stromal compartments, respectively (Figure 1). These ROIs were segmented into CK-positive and SMA-positive clusters. UV exposure liberated the barcodes from the DSP probes, which were quantified using the NanoString nCounter system. Quality control (QC) and normalization were performed using the GeoMx DSP Analysis Suite (28). QC assessments included evaluating probe tag binding density, performing positive control normalization, and establishing minimum thresholds for nuclei and surface area counts. QC cutoffs included AOINucleiCount ≥100, stitched reads >1,000,000, and sequencing saturation ≥80%. Normalization used three housekeeping proteins (histone H3, S6, and glyceraldehyde 3-phosphate dehydrogenase), and relative expression data were obtained separately from the CK-positive and SMA-positive compartments.

Figure 1.
Figure 1.

Regions of interest (ROI) obtained using multilabel immunofluorescence staining of invasive breast carcinoma. (A-C) Case 1. (D-F) Case 2. (G-I) Case 4. For all the cases, the epithelial and stromal compartments are labeled with pan-cytokeratin (green; B, E, and H) and smooth muscle actin (red; C, F, and I).

Bioinformatics. Differentially expressed gene (DEG) analysis was performed using the DESeq2 package (29). Raw data were processed to identify DEGs, applying a threshold of absolute log2 fold change (FC) >1.5 for the epithelial compartment or FC >1.0 for the mesenchymal compartment, and an adjusted p-value<0.05. The results were visualized using the ComplexHeatmap package to generate a heatmap of the DEGs (30), with data scaled by Z-score. Rows (genes) and columns (samples) were clustered to identify patterns. The EnhancedVolcano package facilitated the creation of a volcano plot, highlighting genes with significant and large FCs. Gene ontology enrichment analysis (GOEA) was performed using the enrichGO function from the clusterProfiler package (31) and the org.Hs.eg.db from the OrgDb package. GO terms with p<0.05 were considered statistically significant. Gene set enrichment analysis (GSEA) was performed using the fgsea package with the MSigDB hallmark gene sets. An adjusted p<0.05 was the cutoff value for assessing statistical significance. All statistical analyses were performed using the R software (version 4.3.1, R Foundation for Statistical Computing, Vienna, Austria).

Results

Table I summarizes the baseline clinicopathological characteristics of seven patients with ER-positive, HER2-negative, node-negative breast carcinoma. The age of the patients ranged from 36 to 48 years (mean=43.4 years; median=45 years). All the patients were histologically diagnosed with invasive carcinoma of no special type. Two patients had ORS scores of 30 and 31, placing them in the ORS-high (ORS-H; ORS ≥26) group. The remaining five patients had ORS scores ranging from 2 to 17 (mean=11.8), categorizing them in the ORS-non-high (ORS-NH; ORS <26) group. Tumor sizes varied between 1.1 and 2 cm (mean=1.5 cm). All cases showed hormone receptor positivity, with Allred scores of ER (range=7-8) and progesterone receptor (range=4-8), and none exhibited HER2 immunoreactivity. None of the patients showed lymph node metastasis or histological grade 3. The Ki-67 labeling index in the ORS-H and ORS-NH group was 10.6-21.7% was 5.3-8.4% (mean=6.3%), respectively.

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Table I.

Baseline clinicopathological characteristics of seven patients with invasive breast carcinoma.

The expression of 16 carcinoma-related genes listed in the Oncotype DX multigene assay were compared between the ORS-H and ORS-NH groups (Figure 2). Both the epithelial and stromal compartments showed up-regulation of myeloblastosis proto-oncogene-like 2 (MYBL2) and baculoviral inhibitor of apoptosis repeat containing 5 (BIRC5) in the ORS-H group compared with that in the ORS-NH group. In the epithelial compartment, BIRC5 expression was 6.604 in the ORS-H group and 4.034 in the ORS-NH group, whereas MYBL2 expression was 4.919 and 1.886, respectively. Additionally, cathepsin V (CTSV) expression was significantly higher in the ORS-H group. Conversely, the expression of glutathione S-transferase M1 (GSTM) was significantly lower in the ORS-H group.

Figure 2.
Figure 2.

Expression of 16 carcinoma-related genes from the Oncotype DX multigene assay in the (A) epithelial and (B) stromal compartments of Oncotype DX Recurrence Score-high (ORS-H; red bars) and ORS-non-high (ORS-NH; blue bars) breast carcinomas. AURKA: Aurora kinase A; BAG1: Bcl2-associated athanogene 1; BCL2: B-cell lymphoma 2; BIRC5: baculoviral IAP repeat-containing 5; CCNB1: cyclin B1; CD68: cluster of differentiation 68; CTSV: cathepsin V; ERBB2: erythroblastic leukemia viral oncogene homolog 2; ESR1: estrogen receptor 1; GRB2: growth factor receptor-bound protein 2; GSTM1: glutathione S-transferase Mu 1; MKI67: marker of proliferation Ki-67; MMP11: matrix metalloproteinase 11; MYBL2: Myb-related protein B; PGR: progesterone receptor; SCUBE2: Signal peptide, CUB domain, and epidermal growth factor-like domain-containing 2.

Table II and Table III summarize the differences in gene expression between the ORS-H and ORS-NH groups. In the epithelial compartments of the ORS-H group, 52 significant DEGs were identified, including 25 up-regulated and 27 down-regulated genes. Among the up-regulated genes, trafficking protein particle complex subunit 9 (TRAPPC9), tumor protein D52 (TPD52), and argonaute RNA-induced silencing complex catalytic component 2 (AGO2) showed the highest fold changes (3.87, 3.66, and 3.59, respectively). Their average expression in the ORS-H group was 6.62, 7.41, and 6.05, respectively, whereas that in the ORS-NH group was 4.45, 4.96, and 4.02, respectively. Elongin C (ELOC), cellular retinoic acid-binding protein 2 (CRABP2), and septin 9 (SEPTIN9) were also up-regulated in the ORS-H group (FC=2.57, 2.47, and 2.00, respectively). Meanwhile, complement component 4B (C4B), trefoil factor (TFF3), and serpin family A member 3 (SERPINA3) were the most down-regulated genes (FC=−4.54, −3.86, and −3.09, respectively). The average expression of C4B, TFF3, and SERPINA3 in the ORS-H group was 4.87, 4.63, and 5.42, respectively, whereas that in the ORS-NH group was 9.45, 8.19, and 8.37, respectively.

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Table II.

Differentially expressed genes (DEGs) in the epithelial compartment of Oncotype DX Recurrence Score (ORS)-high invasive breast carcinoma.

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Table III.

Differentially expressed genes in the stromal compartment of Oncotype DX Recurrence Score (ORS)-high invasive breast carcinoma.

In the stromal compartment of the ORS-H group, 22 significant DEGs were identified, including 17 up-regulated and 5 down-regulated genes (Table III). The average expression of lysozyme (LYZ), complement C1q C chain (C1QC), and complement C1q B chain (C1QB) in the ORS-H group was 7.41, 6.98, and 7.31, respectively, whereas that in the ORS-NH group 5.03, 5.36, and 5.61, respectively. LYZ, C1QC, and C1QB showed the highest fold changes in the stromal compartment of the ORS-H group (2.26, 1.90, and 1.88, respectively). Genes up-regulated in the epithelial compartment, such as ELOC, CRABP2, and SEPTIN9, were also significantly up-regulated in the stromal compartment, with fold changes of 1.74, 1.87, and 1.61, respectively. C4B, the most down-regulated gene in the epithelial compartment, was also significantly down-regulated in the stromal compartment of the ORS-H group (FC=−2.14). Figure 3 and Figure 4 display heatmaps (Figure 3) and volcano plots (Figure 4) of the DEGs identified in the epithelial and stromal compartments, respectively.

Figure 3.
Figure 3.

Heatmaps of differentially expressed genes in the (A) epithelial and (B) stromal compartments of Oncotype DX Recurrence Score-high (ORS-H) and ORS-non-high (ORS-NH) invasive breast carcinomas. The normalized expression values are presented as z-scores. The color gradients indicate the degree of expression, with red representing high expression and violet representing low expression. The epithelial compartment heatmap was generated using genes with an absolute fold change (FC) of >1.5 and adjusted p-value of <0.05. The stromal compartment heatmap was generated using genes with an FC>1.0 and adjusted p<0.05.

Figure 4.
Figure 4.

Volcano plots of differentially expressed genes in the (A) epithelial and (B) stromal compartments. Each dot represents a gene, with its position indicating the fold change (FC) in gene expression and its statistical significance. For the epithelial compartment, genes with an FC >1.5 and adjusted p-value of <0.05 are displayed. For the stromal compartment, genes with an FC >1.0 and adjusted p<0.05 are displayed. Red dots in the upper right and left corners represent up-regulated genes in Oncotype DX Recurrence Score-high (ORS-H) and ORS-non-high (ORS-NH) invasive breast carcinomas, respectively. Gray dots represent non-significant (NS) genes. Green dots indicate genes with significant FC only. Blue dots indicate genes with significant p-values only. Red dots indicate genes with both significant FC and p-values.

GOEA was performed to understand the functional roles of the identified genes in the epithelial (Table IV) and stromal (Table V) compartments of the ORS-H group. The epithelial compartment showed minimal enrichment for up-regulated genes. Instead, several GO terms related to ribosomal structure and functions, including ribosomal subunit (counts=15; p<0.001), ribosome (counts=15; p<0.001), cytosolic ribosome (counts=14; p<0.001), cytoplasmic translation (counts=14; p<0.001), and structural constituent of ribosome (counts=15; p<0.001), were significantly down-regulated. In contrast, in the stromal compartment, several GO terms related to immune response were significantly enriched in the ORS-H group. Prominent GO terms (counts ≥12) included lymphocyte-mediated immunity (counts=12; p<0.001), adaptive immune response based on somatic recombination of immune receptors built from immunoglobulin superfamily domains (counts=12; p<0.001), leukocyte-mediated immunity (counts=12; p<0.001), and amide binding (counts=12; p<0.001).

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Table IV.

Enriched gene ontology (GO) categories of down-regulated genes in the epithelial compartment of Oncotype DX Recurrence Score-high invasive breast carcinoma.

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Table V.

Enriched gene ontology (GO) categories of up-regulated or down-regulated genes in the stromal compartment of Oncotype DX Recurrence Score-high invasive breast carcinoma.

Table VI summarizes the top enriched hallmark gene sets in the ORS-H group. GSEA revealed several hallmark gene sets that were significantly up-regulated or down-regulated in the ORS-H group (Figure 5). In the epithelial compartment, the DNA repair pathway was positively enriched (adjusted p=0.018; normalized enrichment score=1.685), whereas the epithelial-mesenchymal transition pathway (adjusted p=0.018; normalized enrichment score=−2.307) and tumor necrosis factor-α signaling via nuclear factor-Embedded ImageB pathway (adjusted p=0.018; normalized enrichment score=−2.133) were significantly down-regulated. The early (adjusted p=0.023; normalized enrichment score=−1.687) and late (adjusted p=0.018; normalized enrichment score=−1.853) estrogen response pathways, coagulation pathway (adjusted p=0.046; normalized enrichment score=−1.710), and hypoxia pathway (adjusted p=0.018; normalized enrichment score=−1.688) were also down-regulated.

View this table:
Table VI.

Top enriched hallmark gene sets in the epithelial and stromal compartments of Oncotype DX Recurrence Score-high invasive breast carcinoma.

Figure 5.
Figure 5.

Gene set enrichment analysis of hallmark pathways in the epithelial compartment. (A) Pink and blue bars represent up-regulated and down-regulated gene sets in Oncotype DX Recurrence Score-high (ORS-H) invasive breast carcinoma, respectively. The length of each bar indicates the normalized enrichment score. (B) The most up-regulated gene set (DNA repair). (C) The most down-regulated gene set (epithelial-mesenchymal transition) in the ORS-H group. The bars at the bottom and top of the panels represent the corresponding genes of specific gene sets. NF: Nuclear factor; TNF: tumor necrosis factor.

In the stromal compartment (Figure 6), the two interferon (IFN)-related pathways, IFN-α response pathway (adjusted p=0.022; normalized enrichment score=2.676) and IFN-γ response pathway (adjusted p=0.022; normalized enrichment score=3.025), showed positive enrichment. Notably, the latter featured key genes such as signal transducer and activator of transcription 1 (STAT1) and human leukocyte antigen (major histocompatibility complex), class II, D-related beta 1 (HLA-DRB1). Additionally, the complement pathway (adjusted p=0.022; normalized enrichment score=2.064) and the phosphoinositide 3-kinase/Akt/mammalian target of rapamycin signaling pathway (adjusted p=0.028; normalized enrichment score=1.780) were significantly up-regulated, featuring key genes, such as C1QC, complement C1q A chain (C1QA), and apolipoprotein C1 (APOC1). The epithelial-mesenchymal transition pathway that was down-regulated in the epithelial compartment, also showed significant down-regulation in the stromal compartment (adjusted p=0.022; normalized enrichment score=−2.529).

Figure 6.
Figure 6.

Gene set enrichment analysis of hallmark pathways in the stromal compartment. (A) Pink bars represent up-regulated gene sets, whereas blue bars represent down-regulated gene sets in Oncotype DX Recurrence Score-high (ORS-H) invasive breast carcinoma. The length of each bar indicates the normalized enrichment score. (B and C) Gene sets with the most significant (B) up-regulation (interferon-γ response) and (C) down-regulation (epithelial-mesenchymal transition) in the ORS-H group. The bars at the bottom and top of the panels represent the corresponding genes of specific gene sets. DN: Down-regulated; mTOR: mammalian target of rapamycin; PI3K: phosphoinositide 3-kinase; UV: ultraviolet.

Discussion

This study presents novel insights by highlighting transcriptomic differences between the ORS-H and ORS-NH groups of patients with breast carcinomas. Utilizing spatial transcriptomic techniques, we explored these differences, providing a deeper understanding of how distinct gene expression profiles influence the behavior of HR-positive breast carcinomas. Our results underscore the importance of recognizing the unique biological mechanisms of each subgroup, thereby paving the way for further investigations into subgroup-specific therapeutic strategies.

The IFN-γ and IFN-α response pathways were the top two significantly enriched gene signatures in the stromal compartment of the ORS-H group. From a therapeutic standpoint, the relationship between IFN response pathways and resistance to cyclin-dependent kinase 4/6 (CDK4/6) inhibitors in ER-positive breast carcinoma is well documented. De Angelis et al. (32) identified the IFN signaling pathway as critical in resistance to CDK4/6 inhibitors. They demonstrated that high baseline IFN signaling correlates with reduced sensitivity to the CDK4/6 inhibitor palbociclib, as well as intrinsic resistance to palbociclib or abemaciclib when combined with aromatase inhibitors in patients with breast carcinoma. In this study, the key gene in the IFN response was STAT1, which was significantly up-regulated in the stromal compartment of the ORS-H group. Chan et al. (33) reported that STAT1 levels are higher in stromal tissue than those in tumor tissue. STAT1 plays a role in immune responses by transducing IFN-γ-related signals and activating cell death pathways (34). De Angelis et al. (32) also found that high STAT1 expression was significantly associated with shorter relapse-free survival in patients with ER-positive breast carcinoma treated with endocrine therapy but without chemotherapy, using The Cancer Genome Atlas and Molecular Taxonomy of Breast Cancer International Consortium datasets. Our findings suggest that identifying patients with up-regulated IFN signaling in the stromal compartment through tumor profiling is crucial for determining appropriate treatment plans. Given the small number of patients in this study, further investigations with larger cohorts are warranted to validate our findings and identify a subset of ORS-H breast carcinoma patients with high IFN signaling.

Our study indicated that the expression levels of complement components, including C1QA, C1QB, and C1QC, were up-regulated in the stromal compartment of the ORS-H group. Additionally, GSEA revealed significant positive enrichment of the complement pathway in the stromal compartment. This finding contrasts with Chen et al. (35), who reported that high expression of C1Q components is associated with a favorable prognosis in patients with osteosarcoma. Similarly, Liang et al. (36) and Yang et al. (37) showed that high C1QA, C1QB, and C1QC levels correlate with better overall survival and positive immune responses in the tumor microenvironment of malignant melanoma. These findings suggest that C1Q components play a protective role in osteosarcoma and malignant melanoma by enhancing immune surveillance and promoting anti-tumor immunity. However, our data from breast carcinoma, specifically the ORS-H group, suggest a different scenario. The up-regulation of C1QA, C1QB, and C1QC in this context may indicate a more complex interaction within the tumor microenvironment, potentially contributing to a more aggressive tumor phenotype and worse prognosis. C1Q-mediated tumor-promoting functions were reported in other carcinomas. C1Q can promote the proliferation, migration, and adhesion of primary cells in malignant pleural mesothelioma (38). Elevated serum C1Q after immune checkpoint inhibitor treatment correlated with a worse prognosis in patients with non-small cell lung carcinoma (39). Bulla et al. (40) even found that C1Q contributes to the progression and invasion of malignant melanoma by promoting tumor cell growth and angiogenesis. Taken together, C1Q may play a dichotomous role in different malignancies. This discrepancy highlights the need for further research to elucidate the role of C1Q components in breast carcinoma. While C1Q components are associated with favorable outcomes, their role in breast carcinoma, particularly in the high-risk group, remains unclear. Understanding whether the increased expression of complement components contributes to immune evasion or other tumor-promoting activities in high-risk breast carcinoma can offer new insights into therapeutic strategies. Exploring the underlying mechanisms of C1Q-mediated interactions in the stromal compartment can reveal critical targets for improving prognosis and developing tailored treatments for patients with ORS-H breast carcinoma.

Study limitations. Despite employing a rigorous research design to minimize confounding variables, the small sample size in each group remains a significant constraint. Furthermore, all patients were from a single institution, potentially limiting the generalizability of our findings. Single-institution studies often face challenges related to external validity. Therefore, further investigations involving larger, multi-institutional cohorts of breast carcinoma are essential to validate our results and enhance the understanding of transcriptomic differences between the ORS-H and ORS-NH groups.

Conclusion

We utilized DSP to generate spatially resolved transcriptomic profiles in patients with breast carcinoma, identifying associations between altered gene and pathway expression and ORS status. Our study reveals significant transcriptomic differences between the ORS-H and ORS-NH groups. Specifically, we demonstrated that the genes and pathways associated with cell-mediated immunity, IFN response, and complement C1q were up-regulated in the stromal compartment of the ORS-H group. Further studies using larger, multi-institutional cohorts of ORS-H breast carcinoma are necessary to validate our observations and explore their clinical and prognostic implications for personalized treatment strategies.

Acknowledgements

This work was supported by the Samsung Medical Center Grant (SMO1240641), the National Research Foundation of Korea (NRF) grant funded by the Korean Government (MSIT) (2023R1A2C2006223), and the Medical Research Funds from Kangbuk Samsung Hospital.

Footnotes

  • Authors’ Contributions

    All Authors made substantial contributions to the conception and design of this work, the acquisition and interpretation of data, the drafting and critical revision of the manuscript for important intellectual content, and the final approval of the version to be published.

  • Conflicts of Interest

    The Authors declare no conflicts of interest or financial ties relevant to the content of this article.

  • Received July 18, 2024.
  • Revision received August 3, 2024.
  • Accepted August 5, 2024.

This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).

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Identifying High Recurrence Risk in Breast Carcinoma Patients Through Spatial Transcriptomic Analysis
JINAH CHU, SUNG-IM DO, HYUN-SOO KIM
Anticancer Research Oct 2024, 44 (10) 4387-4401; DOI: 10.21873/anticanres.17268
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