|Ahead of print publication
A single centre experience in Turkey for comparison between core needle biopsy and surgical specimen evaluation results for HER2, SISH, estrogen receptors and progesterone receptors in breast cancer patients
Hatice Karaman, Fatma Senel, Arzu Tasdemir, Ipek Özer, Merve Dogan
Department of Pathology, Kayseri City Training and Research Hospital, Kayseri, Turkey
|Date of Submission||29-May-2020|
|Date of Decision||16-Jul-2020|
|Date of Acceptance||15-Sep-2020|
|Date of Web Publication||05-Aug-2021|
Alpaslan Street Emrah Ave. Beyoğlu Apt. 21/3 Melikgazi, Kayseri 38030
Source of Support: None, Conflict of Interest: None
Background: Breast carcinoma diagnosis can be made with core-needle biopsy (CNB), but there are controversies regarding the evaluation of hormone receptor (HR) status in needle biopsy specimens. When preoperative neoadjuvant therapy is required in breast cancer cases, the CNB specimen should be evaluated to decide on the treatment.
Objectives: In this study, we aimed to compare the estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), and silver in situ hybridization (SISH) results of the CNB specimens and surgical specimens (SS) of our breast carcinoma cases.
Materials and Methods: This retrospective study included cases diagnosed with breast cancer in our center for approximately 1 year between 2017 and 2018. About 97 cases with both CNB specimens and SS were included in the study. Data such as the ER, PR, HER2, and SISH evaluation results in CNB and SS, age distribution and histopathological type, metastatic lymph nodes, lymphovascular invasion, tumor size, and grade of the tumor were recorded. The data were analyzed using SPSS 22.0 (Statistical Package for the Social Sciences, Armonk, NY, USA) software.
Results: All of the cases were female and 70.1% of them were aged over 45. About 27.8% of the cases were aged 31–45 years, and 2.1% were aged under 30. When evaluated according to the histopathological type of the tumor, 71.1% of cases were invasive ductal carcinoma (IDC), 8.2% were invasive lobular carcinoma (ILC), 6.2% were IDC + ILC, 11.3% were another carcinoma, and 3.1% were in situ carcinoma. 12.4% of the cases were Grade I, 43.3% were Grade II, and 20.6% were Grade III. 43.3% of our cases' tumor size were ≤2 cm and 56.7% >2 cm. 50 (51.5%) of these cases had no lymph node metastasis. It was found out that 36 (37.1%) of the cases had 1–4 metastatic lymph nodes and 11 (11.3%) of them had 5 and more metastatic lymph nodes. It was found out that 44 (45.4.%) of the cases had no lymphovascular invasion and 53 (54.6%) of them had a lymphovascular invasion. When HR statuses in CNB and SS were compared, ER was found to have a sensitivity of 96.1% and a specificity of 100%. PR was found to have a sensitivity of 94.2% and a specificity of 66.7%. HER2 was found to have a sensitivity of 100% and a specificity of 73.4%.
Conclusion: ER evaluation results are reliable in deciding on needle biopsy material. PR may show the heterogeneous distribution in HER2 tumor. Thus, if PR and HER2 results in needle biopsy material are negative, assessments should be repeated in SS.
Keywords: Breast, carcinoma, estrogen, human epidermal growth factor receptor 2, progesterone
|How to cite this URL:|
Karaman H, Senel F, Tasdemir A, Özer I, Dogan M. A single centre experience in Turkey for comparison between core needle biopsy and surgical specimen evaluation results for HER2, SISH, estrogen receptors and progesterone receptors in breast cancer patients. J Can Res Ther [Epub ahead of print] [cited 2022 Jul 3]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=323173
| > Introduction|| |
Breast cancer is 100 times more prevalent in women than men. Although the etiology of breast cancer has not been fully clarified, estrogen exposure is the most important known risk factor. Other risk factors include family history, advanced age, smoking, and alcohol use.,
Core-needle biopsy (CNB) is the gold standard method for diagnosing breast cancer. Pathological evaluation can be performed with high accuracy on appropriate samples and facilitates preoperative treatment planning. When malignancy is detected, it is easy to determine the type of cancer; receptor studies can also be useful.
In the clinical treatment of patients with invasive breast carcinoma, estrogen receptors (ERs), progesterone receptors (PRs), and human epidermal growth factor receptor 2 (HER2) are routinely used as molecular biomarkers. These receptors are targets for breast cancer treatments.
Determination of hormone receptor (HR) status through immunohistochemical methods and needle biopsy is important. With advances in hormonal treatments, the importance of determining ER and PR positivity in tumors has been increasingly recognized. ER- and PR-positive tumors respond better to antiestrogenic therapy and have better prognoses. In addition to systemic chemotherapy, anti-HER2 therapy is provided to HER2-positive patients. Therefore, accurate analysis of HER2 is also crucial.
| > Materials and Methods|| |
Our retrospective study included 97 cases with both CNB and surgical specimens (SS), diagnosed with breast cancer in our center between 2017 and 2018; pathology reports on both types of specimens were evaluated in all cases. The age distribution, histopathological type, tumor grade, metastatic lymph nodes, lymphovascular invasion, tumor size, and ER, PR, HER2, and silver in situ hybridization (SISH) results were recorded. ER and PR were classified as negative (0) or positive (1) [Figure 1] and [Figure 2]. HER2 was classified as negative (1+), suspected (2+), or positive (3+) [Figure 3] and [Figure 4]. SISH was examined in cases with suspected (2+) HER2. SISH was classified as negative (0) or positive (1) [Figure 5]. Routine biomarker assessment and scoring were done according to national guidelines.,,,, For biomarker analysis, we applied a cutoff value of ≥10% for ER and PR positivity. If either ER or PR was positive, then the patient was deemed HR positive. Although 1% has been used as a cutoff for ER positivity, several studies have reported that tumors with ER <1% have characteristics similar to those with 1%≤ ER <10%.
Negative HER2 protein expression was defined as a score of 1+, whereas positive HER2 protein expression was defined as 3+. Equivocal tumors (score of 2+) were subjected to additional in situ hybridization (ISH) in most cases. After ISH assessment, a HER2 copy/C17 control ratio >2.0 and an average HER2 copy number >4.0 signals/cell were classified as HER2 positivity. Negative HER2 status was defined as an IHC score of 0 or 1+, or an ISH HER2/C17 ratio <2.0 and HER2 copy number <4.0 signals/cell. The overall HER2 status was determined based on the combined results of immunohistochemical protein expression and gene amplification analyses and included the ISH HER2/chromosome 17 probe (C17) ratio and the average HER2 copy number.
| > Results|| |
Of the 97 female patients, 68 were aged over 45 years, 27 were aged 31–45 years, and only 2 were aged 30 years or below [Table 1].
The diagnoses were as follows: in situ (3 cases, 3.1%), invasive ductal carcinoma (IDC, 69 cases, 71.1%), invasive lobular carcinoma (ILC, 8 cases, 8.2%), invasive ductal and lobular carcinoma (6 cases, 6.2%), and other invasive carcinomas (11 cases, 11.3%) [Table 2].
Grade I cases comprised 12.4% of the total, whereas 43.3% were Grade II and 20.6% were Grade III [Table 3].
|Table 3: Agreement between the core-needle biopsy and surgical specimens for the grades|
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There was a significant correlation between CNB and SS in terms of ER status (X2 = 63.54, P < 0.000; κ = 0.85, P < 0.000; and Spearman's Rho = 0.86, P < 0.000). The CNB ER status was positive in 76 (78.4%) patients and negative in 13 (13.4%), whereas for SS ER, it was positive in 81 (81.5%) patients and negative in 12 (12.4%). The ER assessment had a sensitivity of 96.1% and specificity of 100%.
There was also a significant correlation between CNB and SS in terms of PR status (X2 = 31.88, P < 0.000; κ = 0.64, P < 0.000; and Spearman's Rho = 0.65, P < 0.000). The CNB PR status was positive in 58 (59.8%) patients and negative in 19 (19.6%), whereas for SS PR, it was positive in 57 (58.8%) patients and negative in 35 (36.1%). The PR assessment had a sensitivity of 94.1% and a specificity of 66.7%.
The correlation between CNB and SS in terms of HER2 was also significant (χ2 = 74.19, P < 0.000; κ =0.54, P <.000; and Spearman's Rho = 0.64, P < 0.000). The CNB HER2 status was positive in 15 (15.5%) patients, negative in 52 (53.6%), and “weak” in 20 (20.6%), whereas for SS HER2, it was positive in 13 patients (13.4%), negative in 69 (71.1%), and weak in 11 (11.3%). The HER2 assessment had a sensitivity of 100% and specificity of 73.4% [Table 4].
|Table 4: Agreement between the core-needle biopsy and surgical specimens for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2|
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The SISH results were examined in 14 cases with suspected (2+) HER2 in CNB specimens; the results were positive in 3 of these cases. The SISH results were also examined in 11 cases with weak HER2 status in SS, 4 of which were positive. The SISH positivity rate was 18.6% in CNB specimens and 17.5% in SS.
| > DİScussİon|| |
Breast cancer is the most common cancer, and the second most common cause of mortality, in women. It is most frequently observed between the ages of 50 and 64 years; those aged below 40 years are affected less often. In our study, 70.1% of the patients were over the age of 45 years. IDC is the most common form of breast cancer, accounting for 40%–75% of all cases; ILC accounts for 5%–15%. In our study, the proportion of IDC cases was 71.1%, and that of ILC cases was 8.2%, similar to the literature.
Needle biopsy, a reliable method for histopathological diagnosis of breast cancer, provides the material necessary for immunohistochemical evaluation of biomarkers. In pretherapeutic biopsies of early breast cancer cases, the status of biomarkers such as ER, PR, and HER2 is of great importance when deciding on treatment, especially when selecting candidates for neoadjuvant chemotherapy.
Three molecular biomarkers are used in the routine clinical management of patients with invasive breast cancer: ER, PR, and HER2. Since all are targets and/or indicators of highly effective therapies against invasive breast cancer in various clinical settings, accurate assessment is essential and mandatory.
The ER is a nuclear transcription factor that, when activated by estrogen, stimulates the development of epithelial cells. The expression of these receptors can be observed by immunohistochemical methods, which are sensitive, specific, easily applicable, and inexpensive. Immunohistochemically, 50%–85% of breast cancers are ER-positive. Similarly, in our study, the ER-positive rate was 81.5%. The response to treatments such as tamoxifen is good in ER-positive cases, and disease-free and overall survival times are longer than in ER-negative cases.
PR is activated by the progesterone hormone, which stimulates the development of tumor cells. PR is expressed in 60%–70% of breast cancers; in our study, 59.8% of cases were PR-positive. ER and PR-positive cases comprise 70% of all cases and have very good responses to hormonal treatment (60%). ER and PR-negative cases account for 25% of all cases; these tumors are unresponsive to treatment (0%). The remaining two phenotypes (ER-positive/PR-negative and ER-negative/PR-positive) show intermediate response rates, although there is debate as to whether the latter tumors actually exist.
The HER2 gene is amplified in 15% of breast cancers, where this amplification is correlated with high levels of protein expression. HER2-positive breast cancers show a good response to HER2-targeted therapy (trastuzumab and lapatinib). In our study, HER2 was amplified in 15.5% of cases, similar to the incidence in the literature.
ER and PR expressions are indicators of good prognosis in breast cancer, whereas HER2 expression is associated with a poor prognosis. Accurate analysis of HER2 is vital. False-negative results regarding HR status can lead to inappropriate hormone therapy. In addition to systemic chemotherapy, anti-HER2 therapy is given to HER2-positive patients.
Determination of HR status is essential when evaluating needle biopsy samples, as has been discussed in the literature. Zidan et al. evaluated the HR status of 26 breast cancer cases with SS and CNB specimens. Negative ER results in CNB specimens were replicated in SS, but no positive results were noted in any of the excised material. They attributed this to that fact that CNB specimens provided better fixation due to their small-tissue volume. Omranipour et al. reported that ER status in SS was positive in 46 (76.6%) cases and negative in 14 (23.3%). The PR status in these samples was positive in 39 (65%) cases and negative in 21 (35%). ER status in CNB was positive in 47 (71.7%) cases and negative in 17 (28.3%), whereas PR status was positive in 43 (71.7%) cases and negative in 17 (28.3%). The CNB ER and PR assessments had sensitivities of 92.9% (66.1%–99.8%) and 81% (58.1%–94.6%), respectively. Both ER and PR had a specificity of about 100% (92.3%–100% and 91%–100%, respectively). Overall, the ER sensitivity was 96.1% and the specificity was 100%; for PR, the respective values were 94.2% and 66.7%. The higher concordance rate for ER compared to PR seen in this study is in line with previous findings., HR positivity is higher in CNB than in SS; therefore, if the CNB result is negative, analysis of SS is recommended. ER positivity decreased from 95% in the CNB to 81.9% in MRM specimens and PR positivity from 93.8% to 86.9%. The overall agreement between CNB and MRM specimens was 81.9% for ER and 85.6% for PR assays. CNB specimens are associated with an identification of more frequent and higher levels of tumoral hormonal receptor proteins than MRM specimens. Delayed fixation of MRM tissues likely accounted for this finding. The optimal selection of patients for hormonal therapies is dependent on tissue management strategies before formal hormonal receptor protein testing procedures.
Chen et al. pooled sensitivity calculated for ER and PR in the study was respectively 97% and 91% when comparing CNB and SS. The accuracy of the test in CNB is high but recommends checking the receptor status in both samples particularly in HR-negative cases.
Meattini et al. reported 101 patients that CNB showed good accuracy in evaluating hormonal receptors status, HER2, and breast cancer molecular subtypes. The concordance rate for HER2 assessment was 91% in the current study. They recommend that it should be detected both on CNB and SS samples, especially in hormonal positive HER2 negative tumors, to avoid misclassification of tumor subtypes that could lead to the omission of potential effective systemic therapy.
Breast cancer is a heterogeneous disease with phenotypic and genetic intratumor heterogeneity. Significant discordance between needle biopsy and surgical resection specimens in terms of HER2 has been reported in heterogeneous tumors. Care should be taken when evaluating HER2 in biopsy specimens, as artifacts can lead to misinterpretation. When HER2 gene amplification is suspected based on the results of immunohistochemical testing, ISH is performed for verification. [27, 34, 35, 36] Even though the concordance rates are high for HER2 status, even minor discordance can have serious implications for patients not receiving life-saving HER2-targeted therapy. In our study, the HER2 positivity rate was higher in CNB specimens than in SS (15.5% and 13.4%, respectively), as was the SISH positivity rate (18.6% and 17.5%, respectively).
The ER evaluation results in CNB specimens are reliable. PR may show a heterogeneous distribution in HER2 tumors. Thus, if PR and HER2 needle biopsy results are negative, assessments should be repeated in SS. However, more work is needed to attain optimal results for IHC assay of HRs in breast cancer because standardization requires control of several variables' fixation, staining method with an appropriate choice of heat-induced antigen retrieval and antibodies, scoring, and interpretation.
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Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]