Spatial Landscape of Pregnancy-Associated Triple Negative Breast Cancer and Mammary Gland Involution

Pregnancy-associated triple negative breast cancer (PA-TNBC) is one of the highest-risk breast cancers, marked by an aggressive phenotype that lacks targeted treatment options. Studies have shown that post-lactational mammary gland involution plays a role in this increased risk. To delineate the underlying mechanisms, our study characterized the transcriptional state of the epithelia and surrounding microenvironment in women with PA-TNBC, comparing those diagnosed pre-involution (PRE) and post-involution (POST, <3 years after delivery). Spatial transcriptomics using the GeoMx Digital Spatial Profiler was performed on treatment-naive PA-TNBC tissues from 33 women (10 PRE, 23 POST). Regions of interest were segmented with pan-cytokeratin staining. We found that the most prominent transcriptional differences between PRE and POST epithelia occurred in the adjacent non-invasive regions and during the transition into invasive TNBC. POST non-invasive epithelia uniquely showed inflammatory and developmental pathway activation, while the transition into TNBC involved increased chromatin remodeling and cell migration pathways. Further, the tumor microenvironment (TME) in POST showed the highest proportion of immune cells and the highest prevalence of tumor- and immune exhaustion-associated cell states. Finally, a pseudotime analysis of POST transcriptional dynamics found that women diagnosed 1-2 years after delivery exhibited the strongest evidence for inflammatory signaling across the tissue. Our results highlight biological mechanisms distinguishing PRE and POST PA-TNBC across tissue regions and cell types. We emphasize the importance of early detection of malignant molecular signatures in morphologically normal epithelium in post-involution women and suggest that targeting the TME may improve treatment efficacy in post-involution PA-TNBC.