Novel patterns of genome rearrangement and their
association with survival in breast cancer
James Hicks,1,10Alexander Krasnitz,1B. Lakshmi,1Nicholas E. Navin,1,2Michael Riggs,1
Evan Leibu,1Diane Esposito,1Joan Alexander,1Jen Troge,1Vladimir Grubor,1
Seungtai Yoon,1Michael Wigler,1Kenny Ye,9Anne-Lise Børresen-Dale,3,4Bjørn Naume,5
Ellen Schlicting,6Larry Norton,7Torsten Hägerström,8Lambert Skoog,8Gert Auer,8
Susanne Månér,8Pär Lundin,8and Anders Zetterberg8
1Cold Spring Harbor Laboratory, Cold Spring Harbor, New York 11724, USA;2Watson School of Biological Sciences, Cold Spring
Harbor, New York 11724, USA;3Department of Genetics, Institute for Cancer Research, Rikshospitalet-Radiumhospitalet Medical
Center, 0310 Oslo, Norway;4Faculty of Medicine, University of Oslo, 0316 Oslo, Norway;5The Cancer Clinic, Rikshospitalet-
Radiumhospitalet Medical Center, 0310 Oslo, Norway;6Department of Surgery, Ullevål Univ. Hospital, 0407 Oslo, Norway;
7Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA;8Karolinska Institutet, Department of
Oncology-Pathology, 171 76 Stockholm, Sweden;9Department of Epidemiology and Population Health, Albert Einstein College of
Medicine, Bronx, New York 10461, USA
Representational Oligonucleotide Microarray Analysis (ROMA) detects genomic amplifications and deletions with
boundaries defined at a resolution of ∼50 kb. We have used this technique to examine 243 breast tumors from two
separate studies for which detailed clinical data were available. The very high resolution of this technology has
enabled us to identify three characteristic patterns of genomic copy number variation in diploid tumors and to
measure correlations with patient survival. One of these patterns is characterized by multiple closely spaced
amplicons, or “firestorms,” limited to single chromosome arms. These multiple amplifications are highly correlated
with aggressive disease and poor survival even when the rest of the genome is relatively quiet. Analysis of a selected
subset of clinical material suggests that a simple genomic calculation, based on the number and proximity of genomic
alterations, correlates with life-table estimates of the probability of overall survival in patients with primary breast
cancer. Based on this sample, we generate the working hypothesis that copy number profiling might provide
information useful in making clinical decisions, especially regarding the use or not of systemic therapies (hormonal
therapy, chemotherapy), in the management of operable primary breast cancer with ostensibly good prognosis, for
example, small, node-negative, hormone-receptor-positive diploid cases.
[Supplemental material is available online at www.genome.org and at http://roma.cshl.edu.]
As cancers evolve, their genomes undergo many alterations, in-
cluding point mutations, rearrangements, deletions, and ampli-
fications, which presumably alter the ability of the cancer cell to
proliferate, survive, and spread in the host (Balmain et al. 2003;
DePinho and Polyak 2004). An understanding of these changes
will allow the design of more rational therapies and, by providing
precise diagnostic criteria, allow fitting the correct therapy to
each patient according to need. Primary breast cancers in par-
ticular exhibit a wide range of outcomes and degrees of benefit
from systemic therapies, which are incompletely predicted by
conventional clinical and clinico-pathological features. This is
especially apparent in the case of small primaries without axillary
lymph node involvement, which usually have a good prognosis
but are sometimes associated with eventual metastatic dissemi-
nation and death.
Breast tumors have long been known to suffer multiple ge-
nomic rearrangements during their development, and thus it is
reasonable to hypothesize that clinical heterogeneity may be
caused by the existence of genetically distinct subgroups. One
common approach to the molecular characterization of breast
cancer has been “expression profiling,” measuring the entire
transcriptome by microarray hybridization. Expression profiling
has been very effective at revealing phenotypic subtypes of breast
cancer and clinically useful diagnostic patterns of gene expres-
sion in tumors (Perou et al. 2000; Sorlie et al. 2001; Ahr et al.
2002; van’t Veer et al. 2002; Sotiriou 2003; Paik et al. 2004).
Expression profiling does not look directly at underlying genetic
changes, and its dependence on RNA, a fragile molecule, creates
some problems in standardization and cross-validation of micro-
array platforms. Moreover, variation in the physiological context
of the cancer within the host, such as the proportion of normal
stroma and the degree of inflammatory response, or the degree of
hypoxia, as well as methods used for extraction and preservation
of sample, are all potentially useful but confounding factors
(Edén et al. 2004).
Direct analysis of the tumor genome provides an alternative
and perhaps, complementary, means of comparing breast tumors
by revealing the genetic events accumulated during tumor pro-
gression. We have begun a long-term genomic study of clinically
well-defined sets of breast cancer patients with a high-resolution
E-mail firstname.lastname@example.org; fax (516) 367-8381.
Article is online at http://www.genome.org/cgi/doi/10.1101/gr.5460106.
Freely available online through the Genome Research Open Access option.
16:1465–1479 ©2006 by Cold Spring Harbor Laboratory Press; ISSN 1088-9051/06; www.genome.org
microarray technique called Representational Oligonucleotide
Microarray Analysis (ROMA) (Lucito et al. 2003). ROMA is based
on the principle that noise in microarray hybridization can be
significantly reduced by reducing the complexity of the labeled
DNA target in the hybridization mix. In its present configuration,
ROMA uses a “representation” of the genome created by PCR
amplification of the smallest fragments of a BglII restriction di-
gest. The representation contains <3% of the complexity of the
normal human genome and is specifically matched with a
unique microarray containing >83,000 oligonucleotide probes
designed to pair with the amplified fragments. Coupled with an
efficient edge-detection or segmentation algorithm, ROMA yields
highly precise profiles of even closely spaced amplicons and de-
letions. At present, ROMA is capable of detecting the breakpoints
of chromosomal events at a resolution of 50 kb. This study is
intended to explore whether high resolution of the genetic
events in tumors can form an additional basis for the clinical
assessment of breast cancer.
The first global studies capable of resolving deletions and
amplifications combined comparative genomic hybridization
(CGH) and cytogenetics (Kallioniemi et al. 1992a,b,c), and this
approach has been applied to breast tumors (Kallioniemi et al.
1994; Ried et al. 1997; Tirkkonen et al. 1998). Subsequently, mi-
croarray methods using CGH have increased resolution and re-
producibility and improved throughput (Ried et al. 1995; Pollack
et al. 2002; Albertson 2003; Lage et al. 2003). These published
microarray studies have largely validated the results of cytoge-
netics CGH, but have not had sufficient resolution to signifi-
cantly improve our knowledge of the role of genetic events in the
etiology of disease, nor assist in the treatment of the patient. On
the other hand, knowledge of specific genetic events, like ampli-
fication of ERBB2, as studied by fluorescence in situ hybridization
(FISH) or Q-PCR, has been clinically useful (van de Vijver et al.
1987; Slamon et al. 1989; Menard et al. 2001). ROMA provides an
extra measure of resolution in genomic analysis that might be
useful in clinical evaluation, as well as delineating loci important
in disease evolution.
We sought to determine whether there were features in the
genomes of tumor cells that correlated with clinical outcome in
a uniform population of women with “diploid” breast cancers.
We chose this population because a significant number of cases
culminate in death despite their clinical and histo-pathological
parameters that would predict a favorable outcome. Our popula-
tion of 99 diploid cancers drew from a bank at the Karolinska
Institute (KI), and was comprised of long-term and short-term
survivors who were similar for node status, grade, and size. For
part of our analysis, we draw on additional studies in progress,
one using 41 aneuploid (defined as >2n DNA content) (see Meth-
ods) cancers from KI, and the other using an additional 103 can-
cers from the Oslo Micrometastasis Study, Oslo, Norway (OMS).
The latter set was not scored for ploidy and has only an average
of 8 yr follow up and is included in this study only for compari-
son of overall frequency of events. The individual genome pro-
files from the KI data set but not the OMS data set are in the
Supplemental material and at (http://roma.cshl.edu). The OMS
data set will be posted as part of a second paper specifically deal-
ing with that group. The makeup of these sample sets with re-
spect to clinical parameters is summarized in Table 1.
Our studies demonstrate a striking similarity of genome pro-
files from two different study populations, as well as the com-
monality of affected loci in aneuploid and diploid cancers. Sig-
nificantly, we observe a different genome profile between diploid
tumors with good and poor outcome. The complexity and the
number of events, captured in a mathematical measure, has led
to our working hypothesis that genomic profiling may be useful
for the molecular staging of breast cancer, and, when validated
by further studies, may have implications for clinical practice.
The clinical makeup of the sample sets included in this study is
summarized in Table 1. The KI tumor data set was assembled
from a collection of >10,000 fresh frozen surgical tumor samples
with detailed pathology profiles and long-term follow up. The
patients in this study underwent surgery between 1987 and 1992
yielding follow-up data for survival of 15–18 yr. The sample set
was assembled with the goal of studying a statistically significant
population of otherwise rare outcomes, particularly diploid tu-
mors that led to death within 7 yr, and aneuploid tumors with
long-term survival (described in Methods). At the same time, the
sample was balanced with respect to tumor size, grade, node
involvement, and hormone receptor status. Treatment informa-
tion is also available in the clinical table available in the Supple-
mental material; however, the sample set was not stratified ac-
cording to treatment because the treatment groups are too frag-
mented to be significant. The Norwegian tumor set was selected
from a trial previously described by Wiedswang et al. (2003) de-
signed to identify markers associated with micrometastasis at the
time of diagnosis (i.e., disseminating tumor cells in blood and
bone marrow). The patients included in the study were recruited
between 1995 and 1998, and fresh frozen tumors were available
for a subset that was not selected for particular characteristics.
Processing individual cancer genomes
We examined all breast cancer genomes with ROMA, an array-
based hybridization method that uses genomic complexity re-
duction based on representations. In the present case, we per-
Distribution of patients and clinical parameters in the Swedish and Norwegian data sets
Karolinska Institutet, SwedenTotal
Median age at
Diploid (survival >7 yr)
Diploid (survival <7 yr)
Oslo Micrometastasis Study (OMS)103 52/46 6310/50/4144/5543/5758/4427/76
Numbers will not add up exactly because of partial information on certain individual cases.
aProgesterone (PR) and estrogen (ER) receptors measured by ligand binding; (pos) ?0.5 fg/µg protein.
bERBB2 amplification scored by ROMA as segmented ratio >0.1 above baseline.
Hicks et al.
formed comparative hybridization using BglII representations,
and arrays of 85,000 oligonucleotide (50-mer) probes with a Pois-
son distribution throughout the genome and a mean interprobe
distance of 35 kb (Lucito et al. 2003). In all cases, we compared
tumor DNA from a patient to a standard unrelated male human
genome. We performed hybridizations in duplicate with color-
reversal, and data were rendered as normalized ratios of probe
hybridization intensity of tumor to normal.
The normalized ratios are influenced by many factors, in-
cluding the signal-to-noise characteristics that differ for each
probe, sequence polymorphisms in the genomes that affect the
BglII representation, DNA degradation of the sample, and other
variation in reagents and protocols during the hybridization and
scan. Statistical processing called “segmentation” identifies the
most likely state for each block of probes, thus reducing the noise
in the graphical presentation of the profile.
Within each raw ROMA profile, segmentation places con-
secutive probe intensity ratios into a series of distinct distribu-
tions, reflecting the alterations that occur when blocks of the
genome are amplified, duplicated, or deleted. Several methods
for segmentation have been published by us and others (Daru-
wala et al. 2004; Olshen et al. 2004), but in the present case, and
in the interest of having very solid findings, we have used a
simplified method that recognizes dis-
tinct distributions of ratio based on
minimization of variance and a Kol-
mogorov-Smirnov test with P-values set
at 10?5(see Methods). All methods con-
verge on roughly the same segmentation
pattern, especially at the boundaries, or
edges, of events, but the simplified
method used herein does not consider
short segments (sets of probes less than
six). On average, the resolution of the
edges of a gene copy number alteration
event is ∼50 kb under our present condi-
tions. We report each probe ratio as the
mean of the medians of the ratios within
the segment to which that probe be-
longs, producing a “segmented profile”
of each cancer. Both raw ratios and seg-
mented ratios are posted on our Web
site. Events less than six probes in length
are, of course, visible in the unseg-
mented data and can be segmented by
other methods, such as Hidden Markov
Models (HMM); however, these very nar-
row events do not affect the conclusions
of this report and are excluded from the
statistical analysis for simplicity.
Single nucleotide polymorphisms
(SNPs), found in all profiles, are present
in our methods that use restriction en-
donuclease-based representations. These
are most often the result of sequence dif-
ferences between sample and reference
that alter the restriction sites used in the
representation process. For purposes of
this report, they merely contribute to
noise and do not significantly affect seg-
mentation. However, both rare copy
number variants (CNVs) and more
prevalent copy number polymorphisms (CNPs) (Sebat et al.
2004) will be present in any high-resolution copy number scan,
regardless of method, when comparing one person to another.
All of our tumor profiles are obtained by comparison to an un-
related standard normal male. If these CNPs and CNVs are not
masked, analysis could mistake either for a cancer lesion. We
have compiled a list of common CNPs and rare CNVs by profiling
healthy cells from 482 individuals, and we used these to mask the
“normal” CNPs in our tumor profiles as described in Methods,
yielding a “masked segmented profile.” We post the masked seg-
mented profiles in the Supplemental material. The collection of
CNPs used for masking includes but is not limited to Scandina-
vian individuals and represents at most a few hundred probes
being removed from consideration for segmentation in any
sample. A CNP falling under a larger (cancer-related) event does
not affect the segmentation of that event. Both the Kolmogorov-
Smirnov segmentation software and the CNP masking algo-
rithms are posted at http://roma.cshl.edu in the forms of scripts
interpretable by R or S+ statistical analysis software.
The mean ratios within segments are not directly propor-
tional to true copy number. The unknown proportion of “nor-
mal” stroma in the surgical biopsies, the potential for clonal
variation, and nonspecific hybridization background signal all
Frequency calculated on normalized, segmented ROMA profiles using a minimum of six consecutive
probes identifying a segment with a minimum mean of 0.1 above (amplification) or below (deletion)
baseline. Frequencies are plotted only for chromosomes 1–22. (A) Total Swedish data set (red) versus
total Norwegian data set (blue). (B) Swedish diploid subset (blue) versus total Swedish aneuploid
subset (red). (C) Swedish diploid 7-yr survivors (red) versus Swedish diploid 7-yr nonsurvivors (blue).
Comparative frequency plots of amplification (up) and deletion (down) in various data sets.
Genome profiles and survival in breast cancer
contribute to a measured segment ratio below the actual copy
number. Although ratios do not directly measure copy number,
differences between the median ratios of segments do reflect dif-
ferences in gene copy within a given experiment. This has been
extensively validated by interphase FISH (see e.g., Fig. 3A,B below).
Event frequency plots in breast cancer and their correlation
Once all the individual profiles are accumulated, they can be
examined and compared as subpopulations. A straightforward,
albeit simplistic, view of genome alterations is the frequency
plot, a measure at each probe of the frequency with which the
probe is amplified or deleted above a threshold in the genome
profiles of a set of cancers. To obtain an overview of breast cancer
lesions, we show plots from the Swedish group, the Norwegian
group, and for the combined set, plotting amplification frequen-
cies as above the line and deletions below (Fig. 1A). Even at this
crude view, it is evident that amplifications and deletions do not
occur at random throughout the genome, and regions that are
amplified tend not to be deleted, and vice versa. Many of the
well-known loci known to be deleted or amplified, such as TP53,
CDKN2A, MYC, CCND1, and ERBB2, are at or near the centers of
frequently altered regions. Additionally, there are frequent
“peaks” and “valleys” where none of the familiar suspects are
found. The data are posted at our Web site, for detailed inspec-
tion by the interested reader.
The Swedish (combined aneuploid and diploid) and Norwe-
gian breast cancers display similar frequency profiles, with
slightly higher frequencies in the Norwegian set. This discrep-
ancy is most likely explained by the high proportion of diploid
cancers in the Swedish set. While the Norwegian set is sequential
and unselected, the Swedish set is >70% pseudo-diploid, selected
according to our working hypothesis that diploids would provide
the most information about tumor development. When we com-
pare the diploid to aneuploid Swedish cancers (Fig. 1B), we again
observe similar profiles along with a similar difference in overall
frequencies. This difference is not apparent when Swedish aneu-
ploids are compared to the Norwegian group (data not shown).
Thus the two cancer types, diploid and aneuploid, share the same
loci of amplification and deletion.
The decreased frequency observed in the diploid set relative
to the aneuploid set can be attributed to the presence of long-
term survivors in the former group. Frequency plots comparing
7-yr (long-lived) survivors to those who do not survive as long
(short-lived) is shown in Figure 1C. Clearly, designating a patient
as a “survivor” or “nonsurvivor” at a specific time is not accurate
in terms of the real progression of the disease. However, it is
useful for understanding the relationship of disease progression
to molecular events. We used 7 yr as a demarcation because it
reflects the point at which the rate of death from cancer in the
worst prognosis group drops to near zero. For the studies de-
scribed in this paper, demarcation values between 7 yr and 10 yr
can be used without changing the basic conclusions. It is quite
apparent that there are fewer overall events, both amplifications
and deletions, in the diploid survivors. Using 25 events as a di-
vider, we obtain the most significant association of the long-lived
versus the short-lived cancer patients, with a P-value of
4.2 ? 10?4by Fisher’s exact test.
Patterns of genome profiles
Visual inspection of segmented profiles suggests that they come
in three basic patterns (Fig. 2), which we present as qualitative
heuristic tools for distinguishing apparently distinct processes of
genomic rearrangement. The first profile pattern (Fig. 2A), which
we call “simplex,” has broad segments of duplication and dele-
tion, usually comprising entire chromosomes or chromosome
arms, with occasional isolated narrow peaks of amplification.
Simplex tumors make up ∼60% of the diploid data set, while the
rest fall into two distinct categories of “complex” patterns. One
of these complex patterns is the “sawtooth” (Fig. 2B), character-
ized by many narrow segments of duplication and deletion, often
alternating, more or less affecting all the chromosomes. Little of
the genome remains at normal copy number, yet the events typi-
cally do not involve high copy number amplification. Note that
the scale of the y-axis in Figure 2B is identical to that in Figure 2A.
It should be further noted that the X-chromosome peak is often
low in sawtooth profiles (e.g., WZ15 in Fig. 2B), indicating that
the X chromosome is not exempt from frequent loss in these
The third pattern (Fig. 2C) resembles the simplex type ex-
cept that the cancers contain at least one localized region of
clustered, relatively narrow peaks of amplification, with each
cluster confined to a single chromosome arm. We denote these
clusters by the descriptive term “firestorms” because we believe
that the clustering of multiple amplicons on single chromosome
arms reflects a concerted mechanism of repeated recombination
on that arm rather than a series of independent amplification
events. The high copy number of these amplicons is reflected in
the scale of the y-axis in Figure 2C.
The two complex patterns, firestorm (25%) and sawtooth
(5%), make up ∼30% of the diploid tumors in this data set. We
cannot perfectly classify all profiles with this system, but the
patterns appear to represent genomic lesions resulting from dis-
tinctly different mechanisms, and more than one mechanism
may be operant to varying degrees within any given tumor.
A fourth type is the “flat” profile, in which we observe no
clear amplifications or deletions other than copy number poly-
morphisms and single probe events, as discussed above, and the
expected difference in the sex chromosomes. These examples are
few in number (14/140) and are not presented graphically here.
Some may result from the analysis of biopsies comprised mostly
of stroma, or some may comprise a clinically relevant set of can-
cers with no detectable amplifications or deletions. Performing
the analyses described in this paper with or without these flat
profiles does not alter our conclusions; hence, we include them
in the analyses presented here.
We used interphase FISH to validate that segmentation is not an
artifact of ROMA or statistical processing of ROMA data. Either
BAC clones or probes created by primer amplification were la-
beled and hybridized to preparations of the same frozen tumor
specimens profiled by ROMA (Methods). Probes were selected
from 33 loci representing both peaks and valleys in the ROMA
profile. In each case, the segmentation values were confirmed by
FISH. We show here representative instances of these data for the
complex pattern of amplification we call “firestorms.”
Firestorms are represented in ROMA profiles as clustered
narrow peaks of elevated copy number. The pattern is limited to
one or a few chromosome arms in each tumor, with the remain-
der of the genome remaining more or less quiet, often indistin-
guishable from the simplex pattern. The individual amplicons in
these firestorms are separated by segments that are not amplified,
Hicks et al.
and are, in fact, often deleted, yielding a pattern of interdigitated
amplification and LOH as shown for chromosome 8 (WZ11) in
Figure 3A and chromosome 11q (WZ17) in Figure 3B. We infer
from this that the phenomenon is a result of sequential replica-
tion and recombination events or breakage and rejoining events
that occur on a particular chromosome arm rather than a general
tendency toward amplification throughout the genome.
One might imagine that the individual peaks in a cluster
arise from clonal subpopulations within the tumor. They do not.
The FISH images of Figure 3 clearly indicate that amplifications at
neighboring peaks of a cluster occur in the same cell. Moreover,
they colocalize in the nucleus. In those cases in which a cell
harbors two firestorms, each on different chromosomes, these
too occur in the same cell, but individually segregate within the
nucleus by chromosome arm, as shown in Figure 3C for CCND1
(cyclin D1) on chromosome 11q and ERBB2 (HER-2/neu) on 17q.
A total of 18 BAC probes representing amplicons and intervening
spaces were used in verifying the structure of chromosome 8 in
WZ11 and 15 primer amplified probes were used for chromo-
some 11 in WZ17. Summary data for all probes are available in
the Supplemental material.
Firestorms have been observed at least once on most chro-
mosomes in the tumors we have analyzed, but certain arms
clearly undergo this process more frequently (see Table 2). In
particular, chromosomes 6, 8, 11, 17, and 20 are often affected,
with 11q and 17q being the most frequently subject to these
dramatic rearrangements. Within the latter, the loci containing
CCND1 on 11q and ERBB2 on 17q are most frequently amplified
and may “drive” the selection of the events. Chromosomes 6, 8,
and 20 have a comparable frequency of firestorms, but the “driv-
ers” for these events are less obvious. However, these potential
“driver” genes are likely not to be the sole reason for the complex
amplification patterns seen in firestorms. The other peaks in the
firestorms are not randomly distributed. Each chromosome ap-
pears to undergo selective pressure to gain or lose specific regions
as exemplified by the frequency plot of chromosome 17 shown
in Figure 4. The histogram of amplification (blue) or deletion
(red) for 27 Grade II and Grade III tumors exhibiting firestorms
on chromosome 17 from both Scandinavian data sets shows dis-
tinct peaks and valleys when compared to the equivalent histo-
gram for a set of tumors of equivalent grade but without chro-
mosome 17 firestorms (black and gray histograms). As shown in
type I or sawtooth; (C) complex type II or firestorm. Scored events consist of a minimum of six consecutive probes in the same state. The y-axis displays
the geometric mean value of two experiments on a log scale. Note that the scale of the amplifications in C is compressed relative to A and B owing to
the high levels of amplification in firestorms. Chromosomes 1–22 plus X and Y are displayed in order from left to right according to probe position.
Major types of tumor genomic profiles. Segmentation profiles for individual tumors representing each category: (A) simplex; (B) complex
Genome profiles and survival in breast cancer
Figure 4, there is a strong tendency for deletion of the distal p
arm including TP53 and for deletion of 17q21 including BRCA1.
Conversely, there are at least four distinct peaks of high-
frequency amplification on the long arm of 17 in addition to the
peak containing ERBB2. As noted in the figure, several genes of
interest for breast cancer are located near the epicenters of these
peaks, including TOB1 (transducer of ERBB2) and BCAS3 (breast
carcinoma amplified sequence). Furthermore, in contrast to ac-
cepted dogma (Jarvinen and Liu 2003), a fraction of the fire-
storms on 17q (5%–10%) do not include amplification of ERBB2,
giving weight to the notion that other loci in the region may
contribute to oncogenesis. In contrast, broad duplications and
deletions are detectable in the non-firestorm subset, but they do
not form clear peaks.
Frequently amplified and deleted loci
It is of interest to note the regions that are most frequently am-
plified or deleted in a large data set such as the one presented
here. There is no single accepted algorithm for deciding which
regions are of most interest, and the parameters used will depend
on the goals of the individual researcher. In Table 3 we present
the results of one such algorithm (see “Frequently Amplified and
Deleted Loci” in Methods) that reflects a component of fre-
quency at any locus plus a factor that gives weight to the inverse
of the width of any given event. The latter is based on the ratio-
nale that narrow events centered on a given locus should carry
more weight than a broad event that happens to encompass that
locus. In the table, the relative value for each locus is shown in
the Index column. Representative genes that have some poten-
tial relation to breast cancer are included for reference purposes,
but we do not presume knowledge of the direct involvement of
specific genes in tumorigenesis based on this analysis. While sev-
eral specific amplicons have been reported previously for specific
chromosomes, such as 11q (Ormandy et al. 2003) and the ERBB2
region of 17q (Jarvinen and Liu 2003), we know of no other
report cataloging a data set of comparable size and resolution
permitting this level of detailed analysis. For example, Ormandy
et al. (2003) report three narrow (<2 Mb) “core” amplicons in the
11q13 bands along with an independent 17-Mb amplicon span-
ning the other three. Our analysis yields roughly equivalent
peaks of high significance (index value) at 11q13.3 and 13.4 in
agreement with their data, along with at least 11 additional dis-
tinct peaks where repeated amplification events have occurred
on that arm. A graphical version of this analysis is available in the
Rearrangements in Grade I tumors
Tumors in which the cells maintain their differentiation as
shown by histological examination are generally considered to
be less aggressive and to have a good prognosis irrespective of
migration to the lymph nodes. Ten examples of these so-called
Grade I tumors were available from the Swedish samples and 13
from the Norwegian collection, including eight in which one or
more nodes were affected. A single noninvasive DCIS (ductal car-
cinoma in situ) sample (MicMa245) was also present in the Nor-
wegian set. All of the Swedish samples were medium to large
tumors between 20 and 30 mm in size, while the Norwegian
samples ranged from 0.5 to 25 mm.
Although the number of samples is small, the similarity in
ROMA profiles among the 13 representative samples depicted in
(Legend on next page)
Hicks et al.
Figure 5 is dramatic and may provide insight into some of the
earliest events leading to invasive breast cancer. Four of the 23
Grade I samples yielded no detectable events (data not shown).
Eighteen of the 19 tumors with any detectable events showed a
characteristic rearrangement in chromosome 16 in which one
copy of 16q appears to be deleted (assuming diploidy) and 16p is
concomitantly duplicated. This rearrangement was also present
in the DCIS sample (MicMa245 in Fig. 5B). The rearrangement of
chromosome 16 is often coupled with either a converse rear-
rangement of the arms of chromosome 8 (8p deleted and 8q
duplicated) or a duplication of the q arm of chromosome 1. All
three of these events are seen in more highly rearranged breast
cancer genomes such as those in Figure 2C and, in fact, are
among the most common events by frequency in all samples (see
Grade I tumors generally display relatively few genomic
events but rarely show more complex patterns of advanced sim-
plex tumors (see MicMa171 in Fig. 5B), indicating that despite a
strong correspondence, there is not a strict relation between ge-
nomic state and histological grade. MicMa171 has progressed to
the point of achieving the common amplicons at 8p12 (Garcia et
al. 2005) and 17q11.2, both of which are noted in Table 3. The
sole Grade I tumor not showing rearrangement of 16p/q (WZ43
in Fig. 5B) exhibits a different pattern with rearrangements of
chromosome 20q and deletion of 22q, indicating that the 16p/q
rearrangement is not the only pathway to tumorigenesis. Al-
though certain of these rearrangements contain obvious candi-
date driver genes such as the duplication of MYC on 8q24 or the
loss of the cadherin (CDH) complex on 16q, the actual target
genes remain the target of further study.
Relation of patterns to clinical outcome
On first inspection, the highly rearranged “sawtooth” and “fire-
storm” patterns appeared to correlate with shorter survival in the
diploid tumors, presumably because selection of novel genetic
combinations afforded the cancer cells the opportunity for accel-
erated recombination. We sought to confirm this observation by
rigorous mathematical and statistical analysis. Using the total
number of segments, or events, as a measure does not clearly
distinguish a sample with a single firestorm from the simplex
pattern with a similar number of events, but the effects of the
firestorm on survival are clear. We chose a mathematical measure
that would separate the sawtooth and firestorm patterns from the
flat and simplex patterns by scoring the close-packed spacing of
the firestorm events, while at the same time incorporating the
total number of events. The sum of the reciprocals of the mean of
lengths of all adjacent segment pairs accomplishes this goal:
where i enumerates all the discontinuities with a magnitude
above a numerical threshold of 0.1 in the segmented profile, and
boring discontinuity on the right (left), or to a chromosome
boundary, whichever is closer. We call this the “inverse adjacent
segment length measure.” This calculation is performed after
masking for CNPs, and does not include the X or Y chromo-
somes. The measure works equally well if absolute position in the
genome is substituted for probe number. Using this algorithm,
the sawtooth patterns achieve a high F because of the sheer num-
L) denotes the number of probes in the closest neigh-
diploid tumor WZ11. The graph shows the normalized raw data (gray) and segmented profile (red) along with the genes for which the probes shown
in the FISH images were constructed. Several distinct conditions are exemplified in the images. First, the ROMA profile indicates that the 8p arm is
deleted distal to the 8p12 cytoband yielding a single copy of DBC1 (green), but >10 tightly clustered copies of BAG4, which is located in the frequently
amplified 8p12 locus (Garcia et al. 2005). Tight clusters of multiple copies corresponding to ROMA peaks are also shown in the FISH images for CKS1A,
MYC, TPD52, and the uncharacterized ORF AK096200. Note that the FISH signals corresponding to distinct loci cluster together irrespective of their
distance on the same arm (CKS1A/MYC) or across the centromere (BAG4/AK096200). Finally, the spaces between ROMA peaks on 8q, exemplified by
NBN (formerly known as NBS1), uniformly show two copies as indicated by the ROMA profile. (B) Expanded view of the centromere and 11q arm from
diploid tumor WZ17 showing correspondence of the copy number as measured by FISH with the copy number predicted by the ROMA profile. The y-axis
represents the segmented ratios of sample versus control. Chromosome position on the x-axis is in megabases according to Freeze 15 (April 2003) on
the UCSC Genome Browser (Karolchik et al. 2003). FISH probes were amplified from primers identified from specific loci using PROBER software
(Methods).The insert outlined in black is magnified to show specific details. Comparative data for the probes shown in black are not shown but are
available on our Web site. In the boxed region, note that in the nonamplified regions the ROMA profile predicts two copies of the arm proximal to the
leftmost amplification. Consistent with the profile, the FISH image shows two copies of probe 11Q3, with one of the spots located in the cluster along
with the amplified copies. The amplicon to the right yields four copies by FISH (probe 11Q4). The ROMA profile for the amplicon represented by probe
11Q6 suggests that it is in a region in which the surrounding nonamplified portion of the arm is deleted. This arrangement is commonly observed in
firestorms and is confirmed by the FISH image showing one pair of the loci 11q5 and 11Q6 together, representing the intact arm, and no copy of probe
11Q5 in the amplified cluster of spots for 11Q6. (C) Profile of tumor WZ19 in which two firestorms are observed on chromosomes 11q and 17q. In
contrast to the overlapping clusters shown in A, amplifications on unrelated arms visualized using FISH probes for CCND1 and ERBB2 cluster indepen-
dently in the nucleus.
Validation of peaks and valleys in ROMA profiles by interphase FISH. (A) Expanded ROMA profile of a firestorm on chromosome 8 in the
excluding X and Y
Occurrence of firestorms in the complete Swedish tumor set including both aneuploids and diploids, by chromosome arm,
chromosome arm1p/q 2p/q 3p/q4p/q5p/q 6p/q7p/q8p/q 9p/q10p/q 11p/q
Firestorms 2/3 0/30/10/0 2/03/81/1 6/80/0 0/31/16
chromosome arm12p/q13q14q 15q16p/q 17p/q18p/q19p/q 20p/q21q 22q
Firestorms 3/3424 0/10/16 0/0 3/3 1/700
Firestorms are defined as three segmented events of any width over a threshold ratio of 0.1 on a single arm.
Genome profiles and survival in breast cancer
ber of distributed events, while the firestorm patterns achieve
high F-values even if only a single arm is affected because of the
contribution of proximity (see WZ11 in Fig. 2C).
F is a robust measure separating the diploid cancers into two
populations that have different survival rates. F ranges in value
from zero to a maximum of ∼0.86 for the Swedish diploid group.
For a range of values of F, from 0.08 to 0.1 we find both a sig-
nificant and strong association between the discriminant value
and survival beyond 7 yr. The optimum value for F separating by
survival does not change appreciably when calculated for sur-
vival at 10 yr. As shown in Table 4, 0.08 and 0.09 yield the lowest
P-values (2.8 ? 10?7and 5.9 ? 10?7by Fisher’s exact test), with
0.09 showing the strongest association with the long-lived versus
the short-lived cancer patients, with an odds ratio of 0.07. Analy-
sis was performed using the fisher.test function in the R data
analysis software, which computes an estimate of the odds ratio
for a 2?2 contingency table using the conditional maximum
likelihood estimate. In contrast, the divider based solely on the
number of events without regard to size or proximity has a lower
significance, with a P-value of 4.2 ? 10?4.
A strong association between F and survival is also found
using an alternative statistical procedure that makes no explicit
reference either to a particular discriminant value of F or to a
particular survival time threshold: We divide the Swedish diploid
set into quartiles with respect to F, then apply a log-rank test for
differences in survival in these four groups. The four groups are
found to have different survival properties, with a P-value of
10?7. In Figure 6A, we display the Kaplan-Meier plots of survival
for all Swedish diploids, with a range of discriminant values for F
from 0.08 to 0.1. These plots show dramatically different rates of
survival for tumors above or below the F-discriminant (Fd). The
discriminatory power of F with respect to survival is even more
dramatic when node-positive and node-negative cases are plot-
ted separately as in Figure 6B, using F = 0.09.
While we find association between F and survival, we find
no significant association between F and either tumor size,
lymph node status, grade, or expression of the estrogen (ER) and
progesterone (PR) receptors (see Table 4; Methods). In other
words, F is an independent clinical parameter. This result does
not imply that these other parameters do not predict disease
recurrence, or that in a random accrual F would not associate
with them. Rather, it reflects that our two groups of diploids,
short-term and long-term survivors, were picked to be balanced
for lymph node status, tumor size, and so forth, and that F has
predictive value independent of these traditional clinical mea-
sures. We do find significant association between F, on the one
hand, and age at diagnosis and amplifications of the CCND1,
MYC, and ERBB2 loci, on the other hand. However, as we show in
the following, F retains its predictive value for survival after ad-
justment for the effects of these four factors.
To further study the effect of F on survival, we fit our data to
a Cox proportional hazards model, starting with a 63-case subset
of the Swedish diploid data set for which we have complete in-
formation on all the clinical parameters listed in Table 4. A clini-
cal parameter is considered significant for survival if the corre-
sponding P-value is below 0.05. As shown in Table 5, we perform
several rounds of analysis, each time removing from consider-
ation clinical parameters not found significant in the previous
round. This reduction in the number of parameters, in turn, al-
lows us to increase the data set for which the information on the
remaining parameters is complete. As a result, we find that F and
the age at diagnosis are the only covariates that remain statisti-
cally significant through all the rounds of analysis. A fit to the
entire Swedish diploid data set gives 4.4 as a hazard ratio for F,
adjusted for the age at diagnosis.
To the best of our knowledge, this study represents the first large
sample set of primary breast tumors profiled for copy number at
a resolution of <50 kb, and using a set of probes designed spe-
cifically to cover the genome evenly without regard to gene po-
sition. Coupled with a segmentation algorithm that accurately
reflects event boundaries, this design has allowed us to examine
genome rearrangements in tumors at an unprecedented level of
detail. At this resolution, narrow and closely spaced amplifica-
tions and deletions, some as narrow as 100 kb, are clearly distin-
guished, and can be validated as discrete events by interphase
Cataloging the events observed in these tumor sets has al-
lowed us to create a high-resolution map of the regions most
frequently affected in this collection of tumors as compiled in
Table 3. Furthermore, examination of the ROMA patterns has led
us to discern three distinct profile types, described as simplex,
sawtooth, and firestorm, that provide insights into the natural
history of tumor development and, moreover, provide prognos-
tic and predictive information that may be of use in clinical
Each of the three characteristic profiles shown by example in
Figure 2 provides a different insight into the biology of primary
breast tumors. Simplex profiles are characterized by multiple du-
plications and deletions of whole chromosomes or chromosome
arms. Moreover, certain specific chromosome arm gains and
losses are highly favored, and at least a subset appears in nearly
containing clustered amplifications (firestorms) on chromosome 17. Lines
represent histograms of the number of events for each probe in seg-
mented ROMA profiles over threshold as in Figure 1 for two subsets
extracted from the combined Scandinavian data set. Blue and red lines
represent amplifications and deletions, respectively, in the subset of 23
tumors containing firestorms on chromosome 17, each showing clear
peaks (valleys) of activity. Black and gray lines represent equivalent events
in a set of 53 tumors in which firestorms are not observed on chromo-
Frequency plots of amplification and deletions in tumors
Hicks et al.
all simplex tumors, even those low-grade tumors with less than
three total events (Fig. 5). These lesions, all of which have been
reported elsewhere by various methods (Kallioniemi et al. 1994;
Ried et al. 1995; Tirkkonen et al. 1998; Pollack et al. 2002;
Nessling et al. 2005), are duplication of 1q, 8q, and 16p, and
deletion of 8p, 16q, and 22q. Each of these shows high frequency
in the set of diploid tumors (Fig. 1B). Not all of the events occur
together in the same tumor, and there is not enough data as yet
to test whether there is any intrinsic order to the timing of their
appearance. We do note, however, that the frequency of these
specific changes remains constant when we compare tumors
from surviving patients (or those with few events) with subsets of
tumors that have poor survival (and many more total events)
(Fig. 1B). One interpretation of these results is that in the early
stages of tumor development, cells undergo a subset of these
specific gain or loss events as they give
rise to proliferating clones. Subse-
quently, as these clones become less dif-
ferentiated and gain potential to spread
in the host, additional events accumu-
late. Thus it is reasonable to speculate
that there are early and late genomic
events that can be separated according
to the degree of progression exhibited by
Comparing Figure 2, A and C, it is
apparent that the complex firestorm
profiles display a spectrum of whole arm
events reminiscent of the simplex pro-
files, but with the notable difference that
certain chromosomes are covered almost
completely with high copy number,
closely spaced amplicons. We call these
features firestorms because they must be
the result of violent disruptions of at
least one homolog, probably involving
multiple rounds of breakage, copying,
and rejoining to form chains of many
copies (up to 30 copies in some cases, as
measured by FISH). The copies appar-
ently remain contiguous since in all
cases tested, FISH results indicate that
the copies fall in tight clusters within the
Firestorms might arise through one
or more previously characterized genetic
mechanisms that have been previously
characterized in cultured cells, such as
breaks at fragile sites (Coquelle et al.
1997; Hellman et al. 2002) or recombi-
nation at pre-existing palindromic sites
(Tanaka et al. 2005), perhaps by short-
ened telomeres. Initial joining of chro-
matids or chromosomes can lead to
breakage-fusion-bridge (BFB) processes
first described by McClintock (1938,
1941). The process of chromatid fusion
and bridge formation is often seen in tu-
mor cells (Gisselsson et al. 2000; Shuster
et al. 2000) and has the potential to re-
sult in repeated rounds of segmental am-
plification while remaining limited to a
single arm as we have documented for firestorm events. This in
itself might be a mechanism for genetic instability that augurs
poor outcome, for example, by enabling the cancer cell to
“search” locally for combinations of genes that by amplification
or deletion promote resistance to natural controls on cell growth,
invasion, or metastasis.
Finally, the alternative complex pattern, which we call saw-
tooth, demonstrates the operation of a path to complex genomic
alteration distinct from that leading to firestorms. In contrast to
firestorms, the sawtooth pattern consists of up to 30 duplication
or deletion events, mostly involving chromosomal segments sig-
nificantly broader than firestorm amplicons and distributed
nearly evenly across the genome. Sawtooth profiles seldom show
high copy number amplification as noted by the difference in the
y-axis scale between Figure 2, A and B, versus Figure 2C. Sawtooth
Swedish diploid tumor set
Loci that undergo frequent amplification or deletion among members of the
Chromosome positionBand Gene symbolIndexmiRNA
Genome profiles and survival in breast cancer
profiles, like firestorms, are associated with a poor prognosis, but
their relatively high F index comes from the sheer number of
events rather than the close spacing of the amplicons in fir-
estorms. Taken together, these differences indicate that a ge-
nome-wide instability has been established in these tumors, per-
haps distinguishing a distinct ontogeny and pathway toward me-
The “Firestorm Index”
The high resolution of the ROMA technique along with our seg-
mentation algorithm has enabled us to visualize narrow and
closely spaced chromosomal rearrangements, in particular, those
that make up the complex firestorm patterns. The validity of the
amplicon assignments, and hence of the Kolmogorov-Smirnov
methodology, has been validated by FISH in all cases tested.
Coupled with the long-term survival and ploidy data available
for the Swedish data set, we derived a working hypothesis con-
sistent with previously reported work (Al-Kuraya et al. 2004; Loo
et al. 2004) that complexity of rearrangement is a negative prog-
nostic factor, but with the novel addition that the closely spaced
events in firestorms make a disproportionately large contribution
to that prognosis.
We have, therefore, derived a molecular signature, F, that
correlates with survival in a subset of tumors, namely, pseudo-
diploid tumors of patients from Scandinavia. The signature is a
simply defined mathematical measure that incorporates two fea-
tures of the genome copy number profile, namely, the number of
distinguishable amplification and deletion segments, and the
close packing of these segments. It is easy to imagine that the
number of distinguishable events can serve as a marker for ma-
lignant “progression.” A large number of events might reflect
either an unstable genome, a cancer that has been growing for a
longer time within the patient and hence has had more oppor-
tunity to metastasize, or a cancer that has undergone more se-
lective events than a cancer with fewer “scars” in its genome. It
is worth noting that even a single case of the clustered amplifi-
cations that we call firestorms appears to be a prognostic indica-
tor of poor outcome.
Our preliminary analyses of this selected sample set indicate
that prognoses in primary breast cancer, measured by the prob-
ability of overall survival, are correlated with the morphology of
the gene copy number signature. Within the balanced group of
our samples, the magnitude of the signature is independent of
such established clinical markers as node status, histologic grade,
and primary tumor size. Hence, it is reasonable to expect that the
signature will contribute to the prediction of outcome, perhaps—
as suggested by our data—in combination with other known fac-
tors. A particularly valuable role for the signature may be in the
estimation of survival for patients with ostensibly good progno-
sis, node-negative breast cancer, a group that may or may not
benefit from systemic therapy. A clear
potential application of such a measure
is in the determination of prognosis,
with a focus on the identification of pa-
tients with such excellent prognoses
that systemic therapy is not required or,
conversely, such poor prognoses—in
spite of clinical measurements that
might be misleading in this regard—that
systemic treatment is absolutely indi-
cated. For example, a patient with a
small, estrogen-receptor-positive, node-
negative primary breast cancer—all fac-
tors that usually indicate a good progno-
sis—might have an especially poor prog-
nosis as predicted by our method.
Further work with unselected sample
sets will, of course, be required to extend
these findings beyond the working hy-
We expect further gains in outcome pre-
diction that uses knowledge of which in-
dividual loci are amplified or deleted in a
specific cancer. Indeed, there are clearly
loci, such as 1q, 8p and 8q, 16p and 16q,
and 22q that are present in both out-
come groups with almost equal fre-
quency, and others, such as 1p12–13,
11q12 and 11q13, 9p, 10q, 17q, and 20q
that are present predominantly in the
cancers from patients with poor out-
comes. We can improve the separation
of the two groups in our own data set by
adding rules that proscribe amplification
or deletion at specific loci or combina-
Chromosome positionBand Gene symbolIndexmiRNA
The Index represents a relative measure that combines frequency and the inverse width of the ampli-
con or deletion (Methods). Loci in the table were selected to have an index of 0.05 or greater.
Hicks et al.
tions of loci. However, despite exhaustive attempts, we could not
convince ourselves that additional improvement in outcome pre-
diction based on knowledge of specific loci was more than one
would expect by chance, given overall event frequencies. The
literature does contain many reports that specific amplifications
or deletions correlate with poor prognosis (Berns et al. 1995;
Jarvinen and Liu 2003; Al Kuraya et al. 2004; Chunder et al. 2004;
Knoop et al. 2005; Madjd et al. 2005). While these reports may,
indeed, be correct, they may also be a consequence of the larger
picture, namely, that there are more lesions in “progressed” can-
cers. The copy numbers of specific genes may also be useful in
clinical decision-making, following the clear demonstration that
ERBB2 amplification—now determined by FISH—conveys both
prognostic and therapeutic information. For example, patients
with amplified ERBB2, as determined by FISH, are now treated
with Herceptin. This determination can be made as well by
ROMA or other methods for genome profiling, and such profiling
may be more informative about which patients have amplifica-
tions and which benefit from such treatment. Other events in the
genome can also indicate different choices of therapy. For ex-
ample, two of the patients in our study exhibit amplification at
the EGFR locus rather than ERBB2, and such patients might ben-
efit from treatment with drugs targeted to that oncogene such as
Tarceva. There are other such examples in the data set. More data
than we now have will be needed to fully test a better outcome
predictor model based on specific loci.
Scandinavian tumor sets
In the course of this study, and to gain a perspective, we have
compared ROMA profiles from two independent sets of tumors
from Sweden and Norway, and shown a basic similarity in the
profiles independent of source or collection method. It is note-
worthy that the diploid tumors with poor outcome show a very
similar overall profile to the aneuploid tumors. Thus, whether or
not the two classes of tumors, diploid and aneuploid, have dif-
ferent mechanisms for malignant genome evolution, a subset of
loci recurred in amplifications and deletions in both types.
It is perhaps not surprising that the tumors from Swedish
and Norwegian populations selected for this study have very
similar frequency profiles, given the ethnic and environmental
homogeneity in Scandinavia. It is unclear to us at the moment
whether these populations will show similarity to other breast
tumor sample sets. In any event, the ability to profile cancers
from populations of restricted ethnicity and environment adds a
new tool for those who wish to study the effects of genetics and
environment on cancer. It will be of great interest to assess ge-
nome profiles of other geographically defined groups, with par-
ticular attention to the possibility of inherited patterns of disease
susceptibility or gene–environment interactions.
In this study, we have focused on a restricted question, the rela-
tionship between complex genomic rearrangements and tumor
progression as determined by eventual outcome in breast cancer.
mented ROMA profiles of six node-positive (Fig. 5A) and seven node-
negative (Fig. 5B) Grade I or DCIS tumors, representing a total of 24
examples from the combined Swedish and Norwegian collections. Most
frequent rearrangements are depicted in red.
Comparison of Grade I and DCIS tumors by ROMA. Seg-
Association of clinical parameters with the F measure in the Swedish diploid subset
Fdvalue Clinical parameterDiscriminating principleP-value from Fisher’s exact test Odds ratio
Above or below 7 yr
Above or below 7 yr
Above or below 7 yr
2.8 ? 10?7
5.9 ? 10?7
8.2 ? 10?6
Age at diagnosis
2 vs. 3
Negative or positive
Smaller or larger than 29 mm
Above or below 0.05 fg/µg protein
Above or below 0.05 fg/µg protein
Above or below segment threshold
Above or below segment threshold
Above or below segment threshold
Above or below 57 yr
8.3 ? 10?4
Genome profiles and survival in breast cancer
There are many other interesting questions that we do not ad-
dress in the present paper. We do not examine the related ques-
tion of genomic and molecular markers for survival among an-
euploid cancers. We have not analyzed what the collective pro-
files teach us about the location of candidate oncogenes and
tumor suppressors. The latter is a deceptively complex problem
that we will address subsequently. In the meantime, we post our
genome profiles and associated data on our Web site (http://
roma.cshl.edu) for others to explore. It is evident from even su-
perficial inspection that many recurrent events encompass
known oncogenes (such as ERBB2, CCND1, MYC) and tumor sup-
pressors (such as CDKN2A and TP53), but many do not, such as
a commonly amplified and very narrow region at 8p12, for
which the driver gene has not been definitively identified
(marked with a probe for BAG4 in Fig. 3A; Garcia et al. 2005). We
are also currently analyzing the important question of whether
certain lesions show covariance.
Finally, it is becoming clear through the identification of
gene copy number alterations in tumors in numerous CGH stud-
ies, that there is likely to be a genetic pathway, albeit a complex
one, at work in the evolution of tumors. As the collection of
tumor genomic profiles increases and can be compared with
treatment regimes as well as patient out-
comes, that prognostic information re-
garding clinical outcome will likely be-
come apparent. Thus existence of some
systematic organization to the genomic
events in these tumors raises the intrigu-
ing possibility that we may soon be able
to dissect the pathways that determine
the bridge from noninvasive to invasive
to metastatic cancer.
A total of 140 frozen tumor specimens
was selected from the archives at the
Cancer Center of the Karolinska Insti-
tute, Stockholm, Sweden. Samples in
this particular data set were selected to
represent several distinct diagnostic categories in order to popu-
late groups for comparison by FISH and ROMA. From a total of
5782 cases, analyzed for ploidy at the Division for Cellular and
Molecular Pathology at the Karolinska Hospital at the time of
primary diagnosis (1987–1991), 1601 pseudo-diploids were avail-
able with complete clinical information including ploidy, grade,
node status, and clinical follow up for 14 to 18 yr. Of these, 4.0%
or 64 cases were node-negative nonsurvivors at 7 yr, and 8.0% or
127 cases were node-positive nonsurvivors. Of these, 47 cases
were locally available as frozen tissue and made up the group of
node-negative and node-positive nonsurvivors. The diploid sur-
vivor group was selected from the remainder of the samples in
order to match tumor size and grade.
From the Oslo Micrometastasis study (OMS) (Wiedswang et
al. 2003), fresh frozen samples from the primary tumor from 103
cases were available for analyses by ROMA.
Status of the estrogen and progesterone receptors (ER, PR) was
determined by ligand binding with a threshold value of >0.05
fg/µg DNA for classification as receptor positive for the Swedish
samples. For the Norwegian samples, automatic immunostaining
Index (F). (A) Complete Swedish diploid data set grouped according to three different discriminator
settings (Fd) of F: Fd= 0.08 (red); Fd= 0.09 (blue); Fd= 0.1 (green). (B) Swedish diploid data set
separated into node-negative (red) and node-positive (blue) subsets with Fdset to 0.09.
Kaplan-Meier plots of the Swedish diploid subset grouped according to the Firestorm
Multivariate analysis of clinical parameters shown in Table 3
principle(P)HR CI(P) HR CI(P) HRCI(P) HR CI
Above or below 0.09
Above or below 57 yr
Above or below
Above or below
I, II, or III
Above or below
Above or below
5 ? 10?6
6 ? 10?3
2 ? 10?6
Discriminating values for AD and size were chosen to maximize their association with survival. (HR) Hazard Ratio; (CI) 95% confidence interval for HR;
(NS) not significant. Columns 3 through 5: all the clinical parameters listed were used in the fit; columns 6 through 8: F, AD and MYC amp. were used
in the fit; columns 9 through 14: F and AD were used in the fit. Results in columns 3 through 11 are based on a 63-case subset of the Swedish diploid
set for which all the clinical parameters used were available. Results in columns 12 through 14 are based on the entire Swedish diploid set.
Hicks et al.
1476 Genome Research
was performed using mouse monoclonal antibodies against ER
and PgR (clones 6F11 and 1A6, respectively; Novocastra). Immu-
nopositivity was recorded if ?10% of the tumor cell nuclei were
immunostained. Amplification of the ERBB2 gene was assessed
by FISH on tissue microarray sections using the PathVysion
HER-2 DNA Probe kit (Vysis Inc.).
ROMA DNA microarray analysis
ROMA was performed on a high-density oligonucleotide array
containing ∼85,000 features, manufactured by Nimblegen. Hy-
bridization conditions and statistical analysis have been de-
scribed previously (Lucito et al. 2003).
Sample preparation, microarray hybridization, and image
The preparation of genomic representations, labeling, and hy-
bridization were performed as described previously (Lucito et al.
2003). Briefly, the complexity of the samples was reduced by
making BglII genomic representations, consisting of small (200–
1200 bp) fragments amplified by adaptor-mediated PCR of ge-
nomic DNA (Sebat et al. 2004). For each experiment, two differ-
ent samples were prepared in parallel. DNA samples (10 µg) were
then labeled differentially with Cy5-dCTP or Cy3-dCTP using the
Amersham-Pharmacia Megaprime labeling Kit, and hybridized in
comparison to each other. Each experiment was hybridized in
duplicate, where in one replicate, the Cy5 and Cy3 dyes were
swapped (i.e., “color reversal”). Hybridizations consisted of 25 µL
of hybridization solution (50% formamide, 5? SSC, and 0.1%
SDS) and 10 µL of labeled DNA. Samples were denatured in an MJ
Research Tetrad for 5 min at 95°C, and then pre-annealed for 30
min at 37°C. This solution was then applied to the microarray
and hybridized under a coverslip for 14–16 h at 42°C. After hy-
bridization, slides were washed for 1 min in 0.2% SDS/0.2? SSC,
30 sec in 0.2? SSC, and 30 sec in 0.05? SSC. Slides were dried by
centrifugation and scanned immediately. An Axon GenePix
4000B scanner was used setting the pixel size to 5 µm. GenePix
Pro 4.0 software was used for quantitation of intensity for the
Array data were imported into S-PLUS for further analysis. Mea-
sured intensities without background subtraction were used to
calculate ratios. Data were normalized using an intensity-based
lowess curve fitting algorithm. Log ratio values obtained from
color reversal experiments were averaged and displayed as pre-
sented in the figures.
Statistics and segmentation algorithm
Segmentation views the probe ratio distribution as an ordered
series of probe log ratios, placed in genome order, and breaks it
into intervals each with a mean and a standard deviation. At the
end of this process, the probe data, in genome order, is divided
into segments (long and certain intervals), each segment and
feature with its own mean and standard deviation, and each fea-
ture associated with a likelihood that the feature is not the result
of chance clustering of probes with deviant ratios.
The ratio data are processed in three phases. In the first
phase, we iteratively segment the log ratio data by minimizing
variance, then test the segment boundaries by setting a very
stringent Kolmogorov-Smirnov (K-S) P-value statistic for each
segment relative to its neighboring segment (P = 10?5). No seg-
ment smaller than six probes in length is considered. In the sec-
ond phase, we compute the “residual string” of segmented log
ratio data, adjusting the mean and standard deviation of each
segment so that the residual string has a mean of 0 and a stan-
dard deviation of 1. “Outliers” are defined based on deviance
within the population, and features are defined as clusters of
outliers (at least two). In the third phase, the features are assigned
likelihood. We determine a “deviance measure” for each feature
that reflects its deviance from the remainder of the data string.
We then, in effect, either randomize or model randomization of
the residual string (i.e., look at the residual data in a randomized
order) many times, and collect deviance measures of all features
generated by purely random processes. After binning the features
by their length and their deviance measure, we can determine
the likelihood that a given feature with a given length and devi-
ance measure would have been generated by random processes if
the probe data were noise.
Statistical analysis of segmented data was performed using R
and S+ statistical languages. In particular, the R Survival package
was used for survival analysis.
Masking of frequent CNPs
A large fraction of our collection of genome profiles are of a
self–nonself type, that is, a cancer genome and a reference ge-
nome originate in different individuals. As a result, not all of the
relative copy number variation in the cancer genome is due to
cancer: Some of it reflects copy number polymorphisms (CNPs)
present in the healthy genome of the affected individual. This
noncancerous signal can potentially contaminate subsequent
analysis and must be filtered out. To this end, we examine our
collection of ROMA profiles derived from cancer-free genomes
(∼500 cases in our most recent study). From that collection we
determine the contiguous regions (here to be understood as series
of consecutive ROMA probes) in the genome where CNP frequen-
cies satisfy two conditions: (1) These frequencies are higher than
certain feeverywhere in the region; (2) these frequencies are
higher than certain fs? fesomewhere in the region. This deter-
mination is done separately for the amplification and for the
deletion CNPs. With our present cancer-free collection, the op-
timal values are fe= 0.006, fs= 0.03. Once the mask, that is, the
set of CNP-prone regions of the genome, is known, it is used for
masking likely noncancerous CNPs in cancer genome profiles.
Here we describe the masking algorithm for amplifications; the
algorithm for deletions is completely analogous. If an amplified
segment in a cancer genome profile falls entirely within a mask,
a point (a probe) is selected at random in the segment, and the
neighboring segments on the right and on the left are extended
to that point. If one of the segment’s endpoints is at a chromo-
some boundary, the neighboring segment is extended from the
other endpoint to the boundary. In effect, the CNPs are excised
from the profile in a minimally intrusive fashion.
Frequently amplified and deleted loci
For the purpose of compiling a list of frequently amplified loci,
amplification events are defined as follows. First, the logarithm
of the relative copy number is computed for every segment in the
genome (the segmentation method is described earlier in this
section). Denote the resulting piecewise constant function L(x),
where x is the genome position. Next, (1) the values of L(x) below
a threshold t are replaced by 0. Then (2) we identify event blocks,
that is, contiguous intervals of the genome such that L(x) > 0
everywhere within the interval. For every block, (3) an event
extending over the entire block is added to the list of events. Next
(4) a minimal nonzero value of L(x) is found in each block, and
that value is subtracted form L(x) within that block. The steps (1)
through (4) are iterated as long as L(x) > 0 anywhere in the ge-
nome. The event counting rule for deletions is completely analo-
Genome profiles and survival in breast cancer
gous, with obvious sign changes made throughout the descrip-
tion. We used a value of 0.1 for t in the present study. Once the
events have been identified, we compute for every position in the
genome an event density measure, defined as the sum of inverse
lengths of all the events containing that position. We then iden-
tify positions with the highest event density in every chromo-
Fluorescence in situ hybridization
FISH analysis was performed using interphase cells, and probes
were prepared either from BACs or amplified from specific ge-
nomic regions by PCR. Based on the human genome sequence,
primers (1–2 kb in length) were designed from the repeat-masked
sequence of each CNP interval, and limited to an interval no
larger than 100 kb. For each probe, a total of 20–25 different
fragments were amplified, then pooled, and purified by ethanol
precipitation. Probe DNA was then labeled by nick translation
with SpectrumOrange or SpectrumGreen (Vysis Inc.). Denatur-
ation of probe and target DNA was performed for 5 min at 90°C,
followed by hybridization in a humidity chamber overnight at
47°C. The cover glasses were then removed, and the slides were
washed in 2? SSC for 10 min at 72°C, and slides were dehydrated
in graded alcohol. The slides were mounted with antifade
mounting medium containing DAPI (4?,6-diamino-2-
phenylindole; Vectashield) as a counterstain for the nuclei.
Evaluation of signals was carried out in an epifluorescence mi-
croscope. Selected cells were photographed in a Zeiss Axioplan 2
microscope equipped with an Axio Cam MRM CCD camera and
Axio Vision software.
Probe design for FISH
Hybridization probes for FISH were constructed in one of two
methods. For the interdigitation analysis, probes were created
from bacterial artificial chromosomes (BAC) selected using the
UCSD Genome Browser. For the determination of copy number
in the deletions and amplifications of the aneuploid tumors,
probes were made with PCR amplification of primers identified
through the PROBER algorithm designed in this laboratory
(Navin et al. 2006). Genomic sequences of 100 kb containing
target amplifications were tiled with 50 probes (800–1400 bp).
Oligonucleotide primers were ordered in 96-well plates from
Sigma Genosys and resuspended to 25 µM. Probes were amplified
with the PCR Mastermix kit from Eppendorf (Cat. 0,032,002.447)
from EBV immortalized cell line DNA (Chp-Skn-1) DNA (100 ng)
with 55°C annealing, 72°C extension, 2 min extension time, and
23 cycles. Probes were purified with Qiagen PCR purification col-
umns (Cat. 28,104) and combined into a single probe cocktail
(10–25 µg total probes) for dye labeling and Metaphase/
Measurement of DNA content
The ploidy of each tumor was determined by measurement of
DNA content using Feulgen photocytometry (Forsslund and Zet-
terberg 1990; Forsslund et al. 1996) The optical densities of the
nuclei in a sample are measured and a DNA index is calculated
and displayed as a histogram (Kronenwett et al. 2004) Normal
cells and diploid tumors display a major peak at 2c DNA content
with a smaller peak of G2-phase replicating cells that corresponds
to the mitotic index. Highly aneuploid tumors display broad
peaks that often center on 4c copy number but may include cells
from 2c to 6c or above.
KI samples were collected from patients undergoing radical mas-
tectomy at the Karolinska Insitutet between 1984 and 1991. This
project was approved by the Ethical Committee of the Karolinska
Institute, Stockholm, Sweden (772003). Samples in the OMS set
were collected during 1995–1998 after informed written consent
and analysis protocols approved by the Regional Committee for
Research Ethics, Health Region II, Oslo, Norway (approval
This work was supported by grants to M.W. from the National
Institutes of Health 5R01-CA078544-07; Department of the Army
W81XWH04-1-0477; W81XWH-05-1-0068; W81XWH-04-0905;
The Simons Foundation; Miracle Foundation; Breast Cancer Re-
search Foundation; Long Islanders Against Breast Cancer; West
Islip Breast Cancer Foundation; Long Island Breast Cancer (1 in
9); Elizabeth McFarland Breast Cancer Research Grant; and Breast
Cancer Help Inc. M.W. is an American Cancer Society Research
Professor. This work was supported by grants to A.Z. from the
Swedish Cancer Society (grant number 0046-B05-39XBC), from
the Stockholm Cancer Society (grant number 03:17), and from
the Swedish Research Council (grant number K2006-31X-20081-
01-3). The OMS study has been supported by the Norwegian Can-
cer Society. We are also grateful for critical review by Knut Li-
estøl, Institute for Informatics, University of Oslo and for useful
comments by Xiaoyue Zhao, Cold Spring Harbor Laboratory.
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Received April 4, 2006; accepted in revised form September 14, 2006.
Genome profiles and survival in breast cancer