1
|
Yit LFN, Quek ZHS, Tan TJ, Tan BF, Tan PH, Tan KTB, Sim Y, Wong FY. Curative Approaches for Metaplastic Breast Cancer: A Retrospective Cohort Outcome Review. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00751-X. [PMID: 38950711 DOI: 10.1016/j.ijrobp.2024.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 06/05/2024] [Accepted: 06/19/2024] [Indexed: 07/03/2024]
Abstract
PURPOSE Metaplastic breast cancer (MBC) is a rare and heterogeneous breast cancer subtype, and there are critical gaps in our understanding of its long-term outcomes. This retrospective cohort study aimed to address these gaps by scrutinizing the pathologic and clinical aspects of MBC to enhance clinical decision-making and refine patient care strategies. METHODS AND MATERIALS This registry-based retrospective cohort study included women aged ≥21 years diagnosed with MBC or matrix-producing carcinoma. The data were obtained from January 2001 to August 2020 from the Joint Breast Cancer Registry of Singapore Health Services, which included 23,935 patients. Demographic and clinicopathologic characteristics, neoadjuvant chemotherapy responses, and survival outcomes were analyzed. Statistical assessments involved univariate and multivariate Cox proportional hazards models and Kaplan-Meier survival analyses. RESULTS This study enrolled 170 patients; 87.1% had non-metastatic disease, and 12.9% had metastatic disease. The age of patients at diagnosis ranged from 46 to 65 years (median, 56 years). The cohort's predominant characteristics were triple negative breast cancer (64%), advanced clinical stage (77.6%), node negativity (67.6%), and grade 3 disease (74.1%). In patients receiving neoadjuvant chemotherapy with curative intent treatment (17.6%), neoadjuvant chemotherapy yielded a pathologic complete response of 19.2% and a disease progression rate of 46.2%. Multivariate analysis showed that adjuvant radiation therapy significantly improved overall survival and disease-free survival, with hazard ratios of 0.29 (95% CI, 0.13-0.62; P < .005) and 0.23 (95% CI, 0.10-0.50; P < .005), respectively. Clinical T3 and T4 stages and nodal involvement were associated with poor outcomes. Stable disease after neoadjuvant chemotherapy was associated with poor overall survival and disease-free survival. CONCLUSIONS This study sheds light on the complex landscape of MBC and emphasizes the pivotal role of adjuvant radiation therapy in enhancing patient outcomes. Despite advancements, challenges persist that warrant continued research to refine neoadjuvant chemotherapy strategies and delve into the nuanced factors that influence treatment responses.
Collapse
Affiliation(s)
| | | | - Tira J Tan
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - Boon Fei Tan
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Puay Hoon Tan
- Division of Pathology, Singapore General Hospital, Singapore
| | | | - Yirong Sim
- Division of Surgery & Surgical Oncology, National Cancer Centre Singapore, Singapore
| | - Fuh Yong Wong
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| |
Collapse
|
2
|
Lainé M, Greene ME, Kurleto JD, Bozek G, Leng T, Huggins RJ, Komm BS, Greene GL. Lasofoxifene as a potential treatment for aromatase inhibitor-resistant ER-positive breast cancer. Breast Cancer Res 2024; 26:95. [PMID: 38849889 PMCID: PMC11161925 DOI: 10.1186/s13058-024-01843-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 05/17/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Breast cancers treated with aromatase inhibitors (AIs) can develop AI resistance, which is often driven by estrogen receptor-alpha (ERα/ESR1) activating mutations, as well as by ER-independent signaling pathways. The breast ER antagonist lasofoxifene, alone or combined with palbociclib, elicited antitumor activities in a xenograft model of ER + metastatic breast cancer (mBC) harboring ESR1 mutations. The current study investigated the activity of LAS in a letrozole-resistant breast tumor model that does not have ESR1 mutations. METHODS Letrozole-resistant, MCF7 LTLT cells tagged with luciferase-GFP were injected into the mammary duct inguinal glands of NSG mice (MIND model; 6 mice/group). Mice were randomized to vehicle, lasofoxifene ± palbociclib, fulvestrant ± palbociclib, or palbociclib alone 2-3 weeks after cell injections. Tumor growth and metastases were monitored with in vivo and ex vivo luminescence imaging, terminal tumor weight measurements, and histological analysis. The experiment was repeated with the same design and 8-9 mice in each treatment group. RESULTS Western blot analysis showed that the MCF7 LTLT cells had lower ERα and higher HER2 expressions compared with normal MCF7 cells. Lasofoxifene ± palbociclib, but not fulvestrant, significantly reduced primary tumor growth versus vehicle as assessed by in vivo imaging of tumors at study ends. Percent tumor area in excised mammary glands was significantly lower for lasofoxifene plus palbociclib versus vehicle. Ki67 staining showed decreased overall tumor cell proliferation with lasofoxifene ± palbociclib. The lasofoxifene + palbociclib combination was also associated with significantly fewer bone metastases compared with vehicle. Similar results were observed in the repeat experiment. CONCLUSIONS In a mouse model of letrozole-resistant breast cancer with no ESR1 mutations, reduced levels of ERα, and overexpression of HER2, lasofoxifene alone or combined with palbociclib inhibited primary tumor growth more effectively than fulvestrant. Lasofoxifene plus palbociclib also reduced bone metastases. These results suggest that lasofoxifene alone or combined with a CDK4/6 inhibitor may offer benefits to patients who have ER-low and HER2-positive, AI-resistant breast cancer, independent of ESR1 mutations.
Collapse
Affiliation(s)
- Muriel Lainé
- The Ben May Department for Cancer Research, The University of Chicago, 929 East 57th Street GCIS W421C, Chicago, IL, 60637, USA
| | - Marianne E Greene
- The Ben May Department for Cancer Research, The University of Chicago, 929 East 57th Street GCIS W421C, Chicago, IL, 60637, USA
| | - Justyna D Kurleto
- The Ben May Department for Cancer Research, The University of Chicago, 929 East 57th Street GCIS W421C, Chicago, IL, 60637, USA
| | - Grazyna Bozek
- The Ben May Department for Cancer Research, The University of Chicago, 929 East 57th Street GCIS W421C, Chicago, IL, 60637, USA
| | - Tiffany Leng
- The Ben May Department for Cancer Research, The University of Chicago, 929 East 57th Street GCIS W421C, Chicago, IL, 60637, USA
| | - Rosemary J Huggins
- The Ben May Department for Cancer Research, The University of Chicago, 929 East 57th Street GCIS W421C, Chicago, IL, 60637, USA
| | | | - Geoffrey L Greene
- The Ben May Department for Cancer Research, The University of Chicago, 929 East 57th Street GCIS W421C, Chicago, IL, 60637, USA.
| |
Collapse
|
3
|
Loggie J, Barnes PJ, Carter MD, Rayson D, Bethune GC. Is Oncotype DX testing informative for breast cancers with low ER expression? A retrospective review from a biomarker testing referral center. Breast 2024; 75:103715. [PMID: 38520994 PMCID: PMC10973721 DOI: 10.1016/j.breast.2024.103715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/07/2024] [Accepted: 03/18/2024] [Indexed: 03/25/2024] Open
Abstract
PURPOSE It remains unclear whether patients with HER2-negative, low-estrogen receptor (ER-low)-positive early breast cancer (BC) benefit from Oncotype DX® (ODX) testing. METHODS We conducted a retrospective review of cases referred for ODX testing over a seven-year period from a breast biomarker testing referral center (n = 854). For each case, we recorded the ODX Recurrence Score (RS) along with percentage of ER nuclear positivity and staining intensity on immunohistochemistry. Our criteria for ER-low was defined as ≤10% cells with nuclear positivity and/or weak intensity of staining. Slides from all ER-low cases were reviewed and the reported ODX ER gene scores were recorded. We randomly selected a comparator group of 56 patients with ER > 10% positivity and non-weak staining intensity (ER-high). RESULTS We identified 27 cases (3.2%) that met our criteria for ER-low. Of these, 92.6% had a high RS (>25), and 7.4% had a RS of 25. All cases with ≤10% ER nuclear positivity had a high RS. Most ER-low cases (85.2%) had ODX quantitative ER gene scores in the negative range, whereas all (100%) ER-high cases had positive ER gene scores. CONCLUSION ODX does not appear to add significant additional information to inform treatment decisions for most patients with ER-low BC. Incorporating weak ER staining intensity in addition to low percentage of nuclear positivity identifies about twice as many ER-low patients, although with reduced specificity for high RS. Our study supports the contention that most ER-low early BC should be regarded similarly to ER-negative BC.
Collapse
Affiliation(s)
- John Loggie
- Department of Pathology and Laboratory Medicine, Dalhousie University, 5788 University Ave, Halifax, NS, B3H 1V8, Canada
| | - Penelope J Barnes
- Department of Pathology and Laboratory Medicine, Dalhousie University, 5788 University Ave, Halifax, NS, B3H 1V8, Canada
| | - Michael D Carter
- Department of Pathology and Laboratory Medicine, Dalhousie University, 5788 University Ave, Halifax, NS, B3H 1V8, Canada
| | - Daniel Rayson
- Division of Medical Oncology, Department of Medicine, Dalhousie University, QEII-Bethune Building, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada
| | - Gillian C Bethune
- Department of Pathology and Laboratory Medicine, Dalhousie University, 5788 University Ave, Halifax, NS, B3H 1V8, Canada.
| |
Collapse
|
4
|
Acs B, Hartman J, Sönmez D, Lindman H, Johansson AL, Fredriksson I. Real-world overall survival and characteristics of patients with ER-zero and ER-low HER2-negative breast cancer treated as triple-negative breast cancer: a Swedish population-based cohort study. THE LANCET REGIONAL HEALTH. EUROPE 2024; 40:100886. [PMID: 38745990 PMCID: PMC11092884 DOI: 10.1016/j.lanepe.2024.100886] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/25/2024] [Accepted: 02/27/2024] [Indexed: 05/16/2024]
Abstract
Background Estrogen receptor-low (ER-low) HER2-negative breast cancer has similar pathological and molecular characteristics as triple-negative breast cancer (TNBC), and it is questionable whether it should be considered a separate entity. When the international guidelines lowered the cutoff for ER positivity to ≥1% in 2010, the ≥10% threshold was kept in Sweden. ER-low breast cancer (ER 1-9%) is thus in Sweden treated as TNBC. We aimed to describe patient and tumor characteristics, treatment patterns and overall survival in a Swedish population-based cohort of patients with ER-zero and ER-low HER2-negative breast cancer treated as TNBC. Methods All TNBC cases diagnosed in Sweden 2008-2020 were included in a population-based cohort study. Patient, tumor and treatment characteristics were analyzed by ER-status (ER 0% vs 1-9%), and associations between subgroups compared using χ2 test. Survival endpoint was overall survival (OS), and Kaplan-Meier curves were estimated. Cox proportional hazards models were used to estimate adjusted hazard ratios comparing ER-low to ER-zero. Findings Of the 5655 tumors, 90.1% had an ER expression of 0%, while 9.9% were ER-low. ER-low tumors were grade III in 69.4% (80.8% in ER-zero tumors, p-value = 0.001), with a median Ki67 of 60% (63% in ER-zero tumors, p-value = 0.005). There were no significant differences in given chemotherapy (p = 0.546). A pathological complete response (pCR) was achieved in 28.1% of ER-low tumors (25.1% in ER-zero tumors). In the unadjusted analysis of OS, women with ER-low disease had a borderline but not significantly better OS than those with ER-zero disease (HR 0.84 (95% CI 0.71-1.00), p = 0.052). ER-status 1-9% vs 0% was not associated with OS in the multivariable analysis (HR 1.11 (0.90-1.36)). Distant disease-free survival did not differ by ER-status 0% vs 1-9% (HR 0.97 for ER-zero vs ER-low (0.62-1.53), p = 0.905). After preoperative treatment, the impact of pCR for OS did not significantly differ between ER-zero or ER-low disease. Interpretation ER-low HER2-negative breast cancer has characteristics and prognosis similar to TNBC, when treated in the same way. Therefore, it seems reasonable to use a ≥10% threshold for ER positivity. This would provide patients with ER-low tumors the same treatment opportunities as patients with TNBC, within studies and within clinical routine. Funding This work was financially supported by Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc., Rahway, NJ, USA, in accordance with terms and conditions of a Master Collaboration Agreement between the company and Karolinska Institutet.
Collapse
Affiliation(s)
- Balazs Acs
- Dept of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Dept of Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Hartman
- Dept of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Dept of Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, Sweden
| | - Demet Sönmez
- Center for Observational and Real-World Evidence, MSD, Stockholm, Sweden
| | - Henrik Lindman
- Dept of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Dept of Oncology, Uppsala University Hospital, Uppsala, Sweden
| | - Anna L.V. Johansson
- Dept of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Irma Fredriksson
- Dept of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Dept of Breast-, Endocrine Tumors and Sarcoma, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
5
|
Li M, Zhou S, Lv H, Cai M, Wan X, Lu H, Shui R, Yang W. FOXC1 and SOX10 in Estrogen Receptor-Low Positive/HER2-Negative Breast Cancer: Potential Biomarkers for the Basal-like Phenotype Prediction. Arch Pathol Lab Med 2024; 148:461-470. [PMID: 37406289 DOI: 10.5858/arpa.2022-0370-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 07/07/2023]
Abstract
CONTEXT.— Breast cancer with low (1%-10%) estrogen receptor (ER) expression (ER-low positive) constitutes a small portion of invasive breast cancers, and the treatment strategy for these tumors remains debatable. OBJECTIVE.— To characterize the features and outcomes of ER-low positive patients, and clarify the clinical significance of FOXC1 and SOX10 expression in ER-low positive/HER2-negative tumors. DESIGN.— Among 9082 patients diagnosed with primary invasive breast cancer, the clinicopathologic features of those with ER-low positive breast cancer were characterized. FOXC1 and SOX10 mRNA levels were analyzed in ER-low positive/HER2-negative cases from public data sets. The expression of FOXC1 and SOX10 in ER-low positive/HER2-negative tumors was evaluated by immunohistochemistry. RESULTS.— The clinicopathologic study of ER-low positive tumors indicated more aggressive characteristics compared with those tumors with ER >10%, while they had more overlapping features with ER-negative tumors irrespective of the HER2 status. The intrinsic molecular subtype of ER-low positive cases with high FOXC1 and SOX10 mRNA expression was more likely to be nonluminal. Among the ER-low positive/HER2-negative tumors, 56.67% (51 of 90) and 36.67% (33 of 90) were positive for FOXC1 and SOX10, respectively, which was significantly positively correlated with CK5/6 expression. In addition, the survival analysis demonstrated no significant difference between patients who received and who did not receive endocrine therapy. CONCLUSIONS.— ER-low positive breast cancers biologically overlap more with ER-negative tumors. ER-low positive/HER2-negative cases demonstrate a high rate of FOXC1 or SOX10 expression, and these cases might be better categorized as a basal-like phenotype/subtype. FOXC1 and SOX10 testing may be used for the intrinsic phenotype prediction for ER-low positive/HER2-negative patients.
Collapse
Affiliation(s)
- Ming Li
- From the Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
- the Institute of Pathology, Fudan University, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
| | - Shuling Zhou
- From the Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
- the Institute of Pathology, Fudan University, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
| | - Hong Lv
- From the Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
- the Institute of Pathology, Fudan University, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
| | - Mengyuan Cai
- From the Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
- the Institute of Pathology, Fudan University, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
| | - Xiaochun Wan
- From the Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
- the Institute of Pathology, Fudan University, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
| | - Hongfen Lu
- From the Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
- the Institute of Pathology, Fudan University, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
| | - Ruohong Shui
- From the Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
- the Institute of Pathology, Fudan University, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
| | - Wentao Yang
- From the Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
- the Institute of Pathology, Fudan University, Shanghai, China (Li, Zhou, Lv, Cai, Wan, Lu, Shui, Yang)
| |
Collapse
|
6
|
Jenkins TM, Mehr CR. Updates in the Use of Immunohistochemical Stains in Breast and Gynecologic Pathology. Arch Pathol Lab Med 2024; 148:33-47. [PMID: 37406290 DOI: 10.5858/arpa.2022-0467-ra] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 07/07/2023]
Abstract
CONTEXT.— The use of immunohistochemical stains in breast and gynecologic pathology has become increasingly complex, with various diagnostic, prognostic, and predictive applications. OBJECTIVE.— To provide an update and review of immunohistochemical stains used in the practice of breast and gynecologic pathology. Established and new entities are reviewed, with descriptions of histomorphology and immunohistochemical staining patterns and discussion of interpretive pitfalls. DATA SOURCES.— Data were obtained from review of the English-language literature and firsthand experience of the authors in breast and gynecologic pathology. CONCLUSIONS.— Many entities in breast and gynecologic pathology benefit from evaluation with various immunohistochemical stains. These studies not only aid in the diagnosis and staging of tumors but also can provide prognostic and predictive information. Updated guidelines for recommended ancillary studies such as mismatch repair, p53, and human epidermal growth factor receptor 2 (HER2) studies in endometrium, as well as estrogen and progesterone receptors and HER2 in breast, are discussed. Finally, the use and interpretation of established and novel immunohistochemical stains are discussed in various breast and gynecologic malignancies.
Collapse
Affiliation(s)
- Taylor M Jenkins
- From the Department of Pathology, University of Virginia Health System, Charlottesville (Jenkins)
| | - Chelsea R Mehr
- Diagnostic Medicine Institute, Geisinger Health System, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, Pennsylvania (Mehr)
| |
Collapse
|
7
|
Malainou CP, Stachika N, Damianou AK, Anastopoulos A, Ploumaki I, Triantafyllou E, Drougkas K, Gomatou G, Kotteas E. Estrogen-Receptor-Low-Positive Breast Cancer: Pathological and Clinical Perspectives. Curr Oncol 2023; 30:9734-9745. [PMID: 37999126 PMCID: PMC10670665 DOI: 10.3390/curroncol30110706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 10/30/2023] [Accepted: 11/02/2023] [Indexed: 11/25/2023] Open
Abstract
The expression of estrogen receptors (ERs) in breast cancer (BC) represents a strong prognostic and predictive biomarker and directs therapeutic decisions in early and advanced stages. ER-low-positive BC, defined by the immunohistochemical (IHC) expression of ERs from 1% to 9%, constitutes a distinct subset of total BC cases. Guidelines recommend that a low expression of ERs be reported in pathology reports since the benefit of endocrine therapy in patients with ER-low-positive BC is uncertain. Recently, several cohorts, mostly of a retrospective nature, have been published, reporting the clinicopathological characteristics and outcomes of ER-low-positive BC. However, the majority of the data focus on early-stage BC and the use of (neo)adjuvant therapy, and there is a significant lack of data regarding metastatic ER-low-positive BC. Further factors, including tumor heterogeneity as well as the potential loss of ER expression due to endocrine resistance, should be considered. Including patients with ER-low-positive BC in clinical trials for triple-negative breast cancer (TNBC) might improve the understanding of this entity and allow novel therapeutic approaches. The design and conduction of randomized clinical trials regarding this subgroup of patients are greatly anticipated.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Georgia Gomatou
- Oncology Unit, Third Department of Medicine, “Sotiria” General Hospital for Diseases of the Chest, National and Kapodistrian University of Athens, 152 Messogion Avenue, 11527 Athens, Greece (E.K.)
| | | |
Collapse
|
8
|
Skjervold AH, Valla M, Bofin AM. Oestrogen receptor low positive breast cancer: associations with prognosis. Breast Cancer Res Treat 2023; 201:535-545. [PMID: 37462784 PMCID: PMC10460703 DOI: 10.1007/s10549-023-07040-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/05/2023] [Indexed: 08/29/2023]
Abstract
PURPOSE In this study of oestrogen receptor (ER) Low Positive breast cancers (BC) in three large cohorts of BC patients, we assess associations between levels of ER expression and tumour characteristics and prognosis. METHODS Cases were stratified into patients unlikely to have received adjuvant therapy according to treatment guidelines at time of diagnosis (before 1995), and those who could have received adjuvant therapy (diagnosed in 1995 or later). ER status was divided into < 1%; ≥ 1 < 10%; ≥ 10%. Results were correlated with time of diagnosis, histopathological grade, proliferation status, and molecular subtypes, using Pearson's Chi-square test. For prognosis, hazard ratios and cumulative incidence of death from BC were used. RESULTS Of the 1955 tumours, 65 (3.3%) were ER Low Positive (ER ≥ 1 < 10%). Overall, the highest proportion of ER Low Positive tumours was observed among Luminal B (HER2 +) subtype (9.4%) and grade 3 tumours (4.3%). The risk of death from BC was lower in ER Low Positive and ER ≥ 10% compared to ER-negative cases. Compared to patients diagnosed before 1995, women diagnosed in 1995 or later showed a higher proportion of ER Low Positive BCs, and their tumours were of smaller size, lower grade, and lower proliferative status. There was no significant difference in prognosis compared to those with ER ≥ 10% tumours. CONCLUSION Women with ER Low Positive tumours diagnosed in a time period when adjuvant therapy was available had tumours of smaller size, lower grade, and lower proliferative status, and similar prognosis to those with ER ≥ 10% compared to women diagnosed earlier.
Collapse
Affiliation(s)
- Anette H Skjervold
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Marit Valla
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Pathology, St. Olav's Hospital, Trondheim, Norway
| | - Anna M Bofin
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| |
Collapse
|
9
|
Moldoveanu D, Hoskin TL, Day CN, Schulze AK, Goetz MP, Boughey JC. Clinical Behavior, Management, and Treatment Response of Estrogen Receptor Low (1-10%) Breast Cancer. Ann Surg Oncol 2023; 30:6475-6483. [PMID: 37460743 DOI: 10.1245/s10434-023-13846-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/19/2023] [Indexed: 09/20/2023]
Abstract
INTRODUCTION Estrogen receptor (ER) and progesterone receptor (PR) guide management and impact outcomes of breast cancer (BC). This study compares ER-low (1-10%) with ER-negative (< 1%) and ER-positive (>10%) BC and investigates the significance of PR expression within ER-low disease. PATIENTS AND METHODS All patients with HER2-negative invasive BC were identified from the National Cancer Database 2018-2019. Treatment and outcomes were compared using chi-squared tests and multivariable logistic regression. RESULTS Of 232,762 patients, ER expression was: negative (13.8%), low (2.0%), and > 10% (84.2%). Chemotherapy was given in 83.9% of ER- disease, 82.4% of ER-low/PR- disease, 58.9% of ER-low/PR+ disease, and only in 22.9% of ER+ disease. Within the ER-low subgroup, adjuvant endocrine therapy, recurrence score, and Ki67 varied by PR status (all < 0.01). Patients with ER-low disease selected for neoadjuvant chemotherapy (NAC) were younger and had higher T and N category, tumor grade, and Ki67. With NAC, pathological complete response (pCR) rates were similar between ER-low/PR- and ER-low/PR+ (39.5% and 38.1%, respectively, p = 0.67), and were closer to the ER- group (39.7%) than the ER+ group (8.4%). On multivariable analysis, the adjusted effect of ER status (1-10% versus > 10%) on chemotherapy administration was odds ratio (OR) 8.2 (95% CI 7.3-9.2, p < 0.001) for PR-negative, and OR 3.3 (95% CI 7.3-9.2, p < 0.001) for PR-positive. CONCLUSIONS This study suggests that the tumor features and clinical management of ER-low tumors vary significantly by PR expression. Within ER-low tumors, PR- tumors more closely resemble ER- BC, while PR+ tumors exhibit less aggressive characteristics. In ER-low disease selected for treatment with NAC, response is similar to ER- regardless of PR status.
Collapse
Affiliation(s)
- Dan Moldoveanu
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Amy K Schulze
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
10
|
Makhlouf S, Althobiti M, Toss M, Muftah AA, Mongan NP, Lee AHS, Green AR, Rakha EA. The Clinical and Biological Significance of Estrogen Receptor-Low Positive Breast Cancer. Mod Pathol 2023; 36:100284. [PMID: 37474005 DOI: 10.1016/j.modpat.2023.100284] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 06/05/2023] [Accepted: 07/13/2023] [Indexed: 07/22/2023]
Abstract
Estrogen receptor (ER) status in breast cancer (BC) is determined using immunohistochemistry (IHC) with nuclear expression in ≥1% of cells defined as ER-positive. BC with 1%-9% expression (ER-low-positive), is a clinically and biologically unique subgroup. In this study, we hypothesized that ER-low-positive BC represents a heterogeneous group with a mixture of ER-positive and ER-negative tumor, which may explain their divergent clinical behavior. A large BC cohort (n = 8171) was investigated and categorized into 3 groups: ER-low-positive (1%-9%), ER-positive (≥10%), and ER-negative (<1%) where clinicopathological and outcome characteristics were compared. A subset of ER-low-positive cases was further evaluated using IHC, RNAscope, and RT-qPCR. PAM50 subtyping and ESR1 mRNA expression levels were assessed in ER-low-positive cases within The Cancer Genome Atlas data set. The reliability of image analysis software in assessment of ER expression in the ER-low-positive category was also assessed. ER-low-positive tumors constituted <2% of BC cases examined and showed significant clinicopathological similarity to ER-negative tumors. Most of these tumors were nonluminal types showing low ESR1 mRNA expression. Further validation of ER status revealed that 45% of these tumors were ER-negative with repeated IHC staining and confirmed by RNAscope and RT-qPCR. ER-low-positive tumors diagnosed on needle core biopsy were enriched with false-positive ER staining. BCs with 10% ER behaved similar to ER-positive, rather than ER-negative or low-positive BCs. Moderate concordance was found in assessment of ER-low-positive tumors, and this was not improved by image analysis. Routinely diagnosed ER-low-positive BC includes a proportion of ER-negative cases. We recommend repeat testing of BC showing 1%-9% ER expression and using a cutoff ≥10% expression to define ER positivity to help better inform treatment decisions.
Collapse
Affiliation(s)
- Shorouk Makhlouf
- Nottingham Breast Cancer Research Centre, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom; Department of Pathology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Maryam Althobiti
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Shaqra University, Shaqra, Saudi Arabia
| | - Michael Toss
- Nottingham Breast Cancer Research Centre, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom; Department of Histopathology, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Abir A Muftah
- Department of Pathology, Faculty of Medicine, University of Benghazi, Benghazi, Libya
| | - Nigel P Mongan
- Biodiscovery Institute, School of Veterinary Medicine and Sciences, University of Nottingham, Nottingham, United Kingdom; Department of Pharmacology, Weill Cornell Medicine, New York, New York
| | - Andrew H S Lee
- Department of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Andrew R Green
- Nottingham Breast Cancer Research Centre, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Emad A Rakha
- Nottingham Breast Cancer Research Centre, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom; Department of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Department of Pathology, Hamad Medical Corporation, Doha, Qatar.
| |
Collapse
|
11
|
Wei S. Hormone receptors in breast cancer: An update on the uncommon subtypes. Pathol Res Pract 2023; 250:154791. [PMID: 37672851 DOI: 10.1016/j.prp.2023.154791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 08/21/2023] [Accepted: 09/01/2023] [Indexed: 09/08/2023]
Abstract
Breast cancer is the most common cancer affecting women and is the second leading cause of cancer death among US women. Estrogen receptor (ER) signaling plays a crucial role in mammary gland development and carcinogenesis. Near 80 % of invasive breast cancers are ER-positive (ER+). Endocrine therapies targeting ER have significantly improved the prognostic outcomes in the patients with ER+ breast cancer, and the therapeutic effects are strongly correlated with the levels of the ER expression in tumor cells. Despite being an ER-dependent gene product, PR is not always overexpressed in ER+ tumors, and a small subset of breast cancers demonstrates an ER+/PR- phenotype, and a rare ER-/PR+ subtype also exists. There have been controversies on the biology of these tumor types and the predictive and prognostic power of PR status. Compelling data have shown the distinct biologic characteristics of ER+/PR- and ER-/PR+ tumors. Despite that ER-low breast cancers demonstrate more similarity to ER- tumors, at least a subset of ER-low carcinomas may have a functional ER signaling. Thus, adequate PR expression is essential as its absence indicates impaired ER pathway. Assessment of PR status may not only distinguish the ER+/PR- subset from the ER+ and ER-low tumors, but also differentiate the ER-/PR+ phenotype from the ER- carcinomas, both with therapeutic implications. This article was aimed to provide an up-to-date review focusing on the clinicopathologic characteristics of uncommon subtypes of breast cancer, including ER+/PR-, ER-/PR+, and ER-low breast cancers.
Collapse
Affiliation(s)
- Shi Wei
- Department of Pathology & Laboratory Medicine, University of Kansas Medical Center, 4000 Cambridge Street, Kansas City, KS 66160, United States; Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35249, United States.
| |
Collapse
|
12
|
Chen HL, Huang FB, Chen Q, Deng YC. Impact of estrogen receptor expression level on response to neoadjuvant chemotherapy and prognosis in HER2-negative breast cancers. BMC Cancer 2023; 23:841. [PMID: 37684569 PMCID: PMC10485958 DOI: 10.1186/s12885-023-11368-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 09/04/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Breast cancers with 1-10% cell staining for estrogen receptor (ER) present particular clinical features. The clinical data of estrogen receptor expression level and treatment effect are limited, particularly regarding chemotherapy benefit. We evaluated the pathologic response to neoadjuvant chemotherapy (NAC) in ER low positive tumors (ER staining 1-10%) and compared it with ER > 10% positive tumors (ER staining > 10%) and ER-negative tumors. We further explored the differences in recurrence and survival with respect to the ER expression level. METHOD Patients with stages II and III HER2-negative primary breast cancer who received neoadjuvant chemotherapy followed by definitive surgery were categorized according to their ER percentages into three groups: ER-negative, ER low positive, and ER > 10% positive. Logistic regression models were used to assess the association between each variable and pathologic complete response (pCR). Kaplan‒Meier analysis was used to estimate survival outcomes. Cox models were used to adjust for patient and tumor characteristics. RESULTS A total of 241 patients were analyzed. Of all patients included, 22 (9.1%) had ER low positive tumors, 159 (66.0%) had ER > 10% positive tumors, and 60 (24.9%) were ER-negative. Low ER positivity was significantly associated with a higher pCR rate than ER > 10% positivity (OR, 0.249; 95% CI, 0.067-0.923; P = 0.038). After a median follow-up time of 32 months, the disease-free survival (DFS) and overall survival (OS) of the patients with ER low positive tumors were significantly worse than those of the patients with ER > 10% positive tumors but similar to those with ER-negative tumors. After adjustment for covariates, ER low positive tumors were significantly associated with worse DFS than ER > 10% positive tumors. CONCLUSION Our results indicated that ER low positive breast cancer presents a better response to neoadjuvant chemotherapy and significantly worse prognosis for patients than those with ER > 10% positive tumors, but similar to the ER-negative group. These data support that this category of patients behaves clinically like patients with ER-negative breast cancer and should be treated differently from patients with ER > 10% positive tumors. Further prospective study is needed.
Collapse
Affiliation(s)
- Hai-Long Chen
- Department of Breast Surgery, the Second Affiliated Hospital of Zhejiang, University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Feng-Bo Huang
- Department of Pathology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Qiang Chen
- Department of Breast Surgery, the Second Affiliated Hospital of Zhejiang, University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Yong-Chuan Deng
- Department of Breast Surgery, the Second Affiliated Hospital of Zhejiang, University School of Medicine, Hangzhou, Zhejiang Province, China.
| |
Collapse
|
13
|
Chung C, Yeung VTY, Wong KCW. Prognostic and predictive biomarkers with therapeutic targets in breast cancer: A 2022 update on current developments, evidence, and recommendations. J Oncol Pharm Pract 2023; 29:1343-1360. [PMID: 35971313 DOI: 10.1177/10781552221119797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate and validate the recent and emerging data for prognostic and predictive biomarkers with therapeutic targets in breast cancer. DATA SOURCES A literature search from January 2015 to March 2022 was performed using the key terms breast cancer, clinical practice guidelines, gene mutations, genomic assay, immune cancer therapy, predictive and/or prognostic biomarkers, and targeted therapies. STUDY SELECTION AND DATA EXTRACTION Relevant clinical trials, meta-analyses, seminal articles, and published evidence- and consensus-based clinical practice guidelines in the English language were identified, reviewed and evaluated. DATA SYNTHESIS Breast cancer is a biologically heterogeneous disease, leading to wide variability in treatment responses and survival outcomes. Biomarkers for breast cancer are evolving from traditional biomarkers in immunohistochemistry (IHC) such as estrogen receptor (ER), progesterone receptor (PR) and epidermal growth factor receptor type 2 (HER2) to genetic biomarkers with therapeutic implications (e.g. breast cancer susceptibility gene 1/2 [BRCA1/2], estrogen receptor α [ESR1] gene mutation, HER2 gene mutation, microsatellite instability [MSI], phosphatidylinositol 3-kinase catalytic subunit 3Cα [PIK3CA] gene mutation, neurotrophic tyrosine receptor kinase [NTRK] gene mutation). In addition, current data are most robust for biomarkers in immunotherapy (e.g. programmed cell death receptor ligand-1 [PD-L1], microsatellite instability-high [MSI-H] or deficient mismatch repair [dMMR]). Oncotype DX assay remains the best validated gene expression assay that is both predictive and prognostic whereas MammaPrint is prognostic for genomic risk. CONCLUSIONS Biomarker-driven therapies have the potential to confer greater therapeutic advantages than standard-of-care therapies. The purported survival benefits associated with biomarker-driven therapies should be weighed against their potential harms.
Collapse
Affiliation(s)
- Clement Chung
- Department of Pharmacy, Houston Methodist West Hospital, Houston, TX, USA
| | - Vanessa T Y Yeung
- State Key Laboratory of Translational Oncology, Sir YK Pao Centre for Cancer, Department of Clinical Oncology, Hong Kong Cancer Institute, The Chinese University of Hong Kong, Hong Kong SAR
| | - Kenneth C W Wong
- State Key Laboratory of Translational Oncology, Sir YK Pao Centre for Cancer, Department of Clinical Oncology, Hong Kong Cancer Institute, The Chinese University of Hong Kong, Hong Kong SAR
| |
Collapse
|
14
|
Lee O, Wang M, Hosseini O, Bosland MC, Muzzio M, Helenowski I, Khan SA. Z-Endoxifen prevents aggressive mammary cancers in mice by inhibiting cell proliferation and creating a tumor suppressive microenvironment. Biomed Pharmacother 2023; 162:114607. [PMID: 37001185 DOI: 10.1016/j.biopha.2023.114607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/24/2023] [Accepted: 03/24/2023] [Indexed: 03/31/2023] Open
Abstract
Aggressive estrogen receptor (ER) positive breast cancer is frequently tamoxifen-resistant; alternative endocrine approaches exist for therapy, but not for prevention, particularly in premenopausal women. We examined the efficacy of the selective ER modulator (Z-endoxifen) as monotherapy and in combination with the selective progesterone receptor modulators (onapristone and ulipristal acetate) in the tamoxifen-insensitive C3(1)/SV40TAg mouse mammary tumorigenesis model. Unlike tamoxifen at human equivalent dose (HED) 101 mg/day, endoxifen at HED 24 mg/day significantly increased latency and reduced tumor growth relative to untreated controls. Ulipristal acetate (UPA) at HED 81 mg/day also significantly increased latency however failed to inhibit tumor growth, while onapristone (HED 98 mg/day) had no tumor prevention efficacy in this model. Addition of UPA to endoxifen did not enhance preventive efficacy over endoxifen alone. The expression of genes associated with cell cycle, cell proliferation and extracellular matrix remodeling was similarly repressed by endoxifen and UPA however only endoxifen significantly downregulated prominent genes associated with poor prognosis (Col11a1, Il17b, Pdgfa, Tnfrsf11a). Our results indicate that endoxifen can prevent breast cancers, even when tamoxifen-resistant, through its role in favorable tissue remodeling and immunomodulation.
Collapse
Affiliation(s)
- Oukseub Lee
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Minhua Wang
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Omid Hosseini
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Maarten C Bosland
- Department of Pathology, University of Illinois at Chicago, Chicago, IL, USA
| | - Miguel Muzzio
- Analytical Chemistry Division, Illinois Institute of Technology Research Institute, Chicago, IL, USA
| | - Irene Helenowski
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Seema A Khan
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| |
Collapse
|
15
|
Clinical Features and Prognosis Analysis of Hormone Receptor-Positive, HER2-Negative Breast Cancer with Differential Expression Levels of Estrogen and Progesterone Receptors: A 10-Year Retrospective Study. Breast J 2022; 2022:5469163. [PMID: 36531979 PMCID: PMC9726250 DOI: 10.1155/2022/5469163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 10/08/2022] [Accepted: 10/13/2022] [Indexed: 11/30/2022]
Abstract
Background Estrogen and progesterone receptor status can predict breast cancer patient prognosis and treatment sensitivity, but research on low ER and PR levels and expression balance remains limited. Methods From January 2010 to October 2016, 283 ER+/PR+/HER2-breast cancer patients who met the inclusion criteria were enrolled and divided into the H group (ER > 10%, N = 261) and the L group (1% ≤ ER ≤ 10%, N = 22). Groups were further divided into the HH group (ER > 10%/PR > 20%, N = 201), the HL group (ER > 10%/ER 1% ≤ PR ≤ 20% PR, N = 60), the LH group (1% ≤ ER ≤ 10%/PR > 20%, N = 5), and the LL group (1% ≤ ER ≤ 10%/1% ≤ PR ≤ 20%, N = 17). The LH group was excluded due to its small size, leaving the clinical and prognostic characteristics of 2 large groups and 3 subgroups to be analyzed. Results L group patients had significantly more stage N2 axillary lymph nodes than H group patients (31.8% vs. 9.2%, P = 0.007). Age (P = 0.011), menopause status (P = 0.001), and tumor size (P = 0.024) were significantly different in the HL vs. HH and LL groups. Five-year DFS (94.6% vs. 77.0%, P < 0.001) and 5-year OS (97.2% vs. 85.8%, P = 0.001) rates significantly differed between HH and HL. No significant differences in 5-year DFS (77.0% vs. 81.9%, P = 0.564) or 5-year OS (85.8% vs. 87.8%, P = 0.729) rates were observed between HL and LL; the OS rates of HL and LL were similar. Conclusion In the group of ER+/PR+/HER2-patients, there was no significant prognostic difference between ER-low positive and ER-high positive groups, but low PR expression was significantly associated with a worse prognosis. The role of ER and PR balance in breast cancer progression and individualized treatment requires further investigation.
Collapse
|
16
|
Reinert T, Cascelli F, de Resende CAA, Gonçalves AC, Godo VSP, Barrios CH. Clinical implication of low estrogen receptor (ER-low) expression in breast cancer. Front Endocrinol (Lausanne) 2022; 13:1015388. [PMID: 36506043 PMCID: PMC9729538 DOI: 10.3389/fendo.2022.1015388] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/08/2022] [Indexed: 11/25/2022] Open
Abstract
Breast cancer is a heterogeneous disease, and the estrogen receptor (ER) remains the most important biomarker in breast oncology. Most guidelines set a positive expression threshold of 1% staining in immunohistochemistry (IHC) to define ER positivity. However, different expression levels may be associated with diverse degrees of sensitivity to endocrine therapy as ER expression may impact breast cancer molecular biology as a continuous variable. ER-lo tumors, defined as those with 1-10% ER expression, represent a relatively small subgroup of breast cancer patients, with an estimated prevalence of 2-7%. These tumors are similar to ERneg disease in their molecular landscape, clinicopathological characteristics, prognosis, and response to therapy. Nevertheless, a proportion may retain some degree of ER signaling dependency, and the possibility of responding to some degree to endocrine therapy cannot be completely ruled out. This review article discusses the most important considerations regarding the definition of ER positivity, pathology assessment, prognosis, and therapeutic implication of ERlo breast cancer from the medical oncology perspective.
Collapse
Affiliation(s)
- Tomás Reinert
- Breast Medical Oncology, Oncoclínicas, Porto Alegre, Brazil
- Breast Cancer Group, Latin American Cooperative Oncology Group, Porto Alegre, Brazil
| | - Fanny Cascelli
- Breast Medical Oncology, Oncoclínicas, São Paulo, Brazil
| | | | | | | | - Carlos Henrique Barrios
- Breast Medical Oncology, Oncoclínicas, Porto Alegre, Brazil
- Breast Cancer Group, Latin American Cooperative Oncology Group, Porto Alegre, Brazil
| |
Collapse
|
17
|
Xie Y, Yang L, Wu Y, Zheng H, Gou Q. Adjuvant endocrine therapy in patients with estrogen receptor-low positive breast cancer: A prospective cohort study. Breast 2022; 66:89-96. [PMID: 36209701 PMCID: PMC9551143 DOI: 10.1016/j.breast.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Little is known about the benefits of adjuvant endocrine therapy (ET) in low ER-positive breast cancer (1%-10%) patients. We analyzed the association between ET and breast cancer-specific survival (BCSS) in these patients with respect to the regimen and the duration of ET. METHODS Patients were classified into three groups based on the regimen and duration of ET. The regimens included aromatase inhibitor (AI) monotherapy or sequential tamoxifen followed by an AI (AI/T + AI), or only tamoxifen and no ET. The duration of ET included 2-3 years and >3 years. Multivariate Cox regression analysis was employed to calculate the hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS Of the 10,696 patients diagnosed with breast cancer between 2010 and 2020, 407 women were identified with ER-low positive disease and met the inclusion criteria. During a median follow-up of 5.2 years, patients who received ET improved BCSS. Of them, those with AI/T + AI had increased BCSS compared to patients without ET, after adjusting for demographics and tumor characteristics, especially in ER-low/HER-2-positive breast cancer. After additional adjustment for treatment mode, the association maintained a similar trend. Patients who received >3 years of ET was associated with a better DFS. There was no significant difference in BCSS between patients with 2-3 years and >3 years of ET. CONCLUSION For ER-low patients, findings suggest that ET with AI/T + AI may be a reasonable treatment alternative. This effect should be assessed in randomized studies.
Collapse
Affiliation(s)
- Yuxin Xie
- Department of Medical Oncology of Cancer Center, West China Hospital, Sichuan University, Chengdu, China,Laboratory of Molecular Diagnosis of Cancer, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Libo Yang
- Laboratory of Molecular Diagnosis of Cancer, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, Sichuan, China,Department of Pathology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yanqi Wu
- Department of Medical Oncology of Cancer Center, West China Hospital, Sichuan University, Chengdu, China,Laboratory of Molecular Diagnosis of Cancer, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hong Zheng
- Department of Medical Oncology of Cancer Center, West China Hospital, Sichuan University, Chengdu, China,Laboratory of Molecular Diagnosis of Cancer, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qiheng Gou
- Department of Medical Oncology of Cancer Center, West China Hospital, Sichuan University, Chengdu, China,Laboratory of Molecular Diagnosis of Cancer, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, Sichuan, China,Department of Radiation Oncology and Head & Neck Oncology Division, Cancer Center, West China Hospital, Sichuan University, Chengdu, China,Corresponding author. Department of Medical Oncology of Cancer Center, West China Hospital, Sichuan University, 37 Guoxue Xiang, Wuhou District, Chengdu, 610041, China. Tel: +86-28-85422685
| |
Collapse
|
18
|
Tecalco-Cruz AC, Ramírez-Jarquín JO, Macías-Silva M, Sosa-Garrocho M, López-Camarillo C. Novel Breast Cancer Treatment by Targeting Estrogen Receptor-Alpha Stability Using Proteolysis-Targeting Chimeras (PROTACs) Technology. Breast Cancer 2022. [DOI: 10.36255/exon-publications-breast-cancer-protacs] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
19
|
Yoder R, Kimler BF, Staley JM, Schwensen K, Wang YY, Finke K, O'Dea A, Nye L, Elia M, Crane G, McKittrick R, Pluenneke R, Madhusudhana S, Beck L, Shrestha A, Corum L, Marsico M, Stecklein SR, Godwin AK, Khan QJ, Sharma P. Impact of low versus negative estrogen/progesterone receptor status on clinico-pathologic characteristics and survival outcomes in HER2-negative breast cancer. NPJ Breast Cancer 2022; 8:80. [PMID: 35817765 PMCID: PMC9273627 DOI: 10.1038/s41523-022-00448-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 06/10/2022] [Indexed: 12/21/2022] Open
Abstract
Triple-negative breast cancer (TNBC) is classically defined by estrogen receptor (ER) and progesterone receptor (PR) immunohistochemistry expression <1% and absence of HER2 amplification/overexpression. HER2-negative breast cancer with low ER/PR expression (1–10%) has a gene expression profile similar to TNBC; however, real-world treatment patterns, chemotherapy response, endocrine therapy benefit, and survival outcomes for the Low-ER group are not well known. 516 patients with stage I-III HER2-negative breast cancer and ER/PR expression ≤10% who were enrolled in a multisite prospective registry between 2011 and 2019 were categorized on the basis of ER/PR expression. TNBC (ER and PR < 1%) and Low-ER (ER and/or PR 1–10%) groups comprised 87.4% (n = 451) and 12.6% (n = 65) of patients, respectively. Demographic, clinical, and treatment characteristics, including prevalence of germline BRCA1/2 mutation, racial and ethnic distribution, and chemotherapy use were not different between TNBC and Low-ER groups. No difference was observed in recurrence-free survival (RFS) and overall survival (OS) between TNBC and Low-ER groups (3-year RFS 82.5% versus 82.4%, respectively, p = 0.728; 3-year OS 88.0% versus 83.4%, respectively, p = 0.632). Among 358 patients receiving neoadjuvant chemotherapy, rates of pathologic complete response were similar for TNBC and Low-ER groups (49.2% vs 51.3%, respectively, p = 0.808). The HER2-negative Low-ER group is often excluded from TNBC clinical trials assessing novel treatments (immunotherapy and antibody-drug conjugates), thus limiting efficacy data for newer effective therapies in this group. Given that HER2-negative Low-ER disease displays clinical characteristics and outcomes similar to TNBC, inclusion of this group in TNBC clinical trials is encouraged.
Collapse
Affiliation(s)
- Rachel Yoder
- University of Kansas Cancer Center, Kansas City, KS, USA
| | - Bruce F Kimler
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Kelsey Schwensen
- Department of Internal Medicine, University of Kansas Medical Center, Westwood, KS, USA
| | - Yen Y Wang
- University of Kansas Cancer Center, Kansas City, KS, USA
| | - Karissa Finke
- Clinical Trials Shared Resource, University of Kansas Medical Center, Westwood, KS, USA
| | - Anne O'Dea
- Department of Internal Medicine, University of Kansas Medical Center, Westwood, KS, USA
| | - Lauren Nye
- Department of Internal Medicine, University of Kansas Medical Center, Westwood, KS, USA
| | - Manana Elia
- Department of Internal Medicine, University of Kansas Medical Center, Lee's Summit, MO, USA
| | - Gregory Crane
- Department of Internal Medicine, University of Kansas Medical Center, Overland Park, KS, USA
| | - Richard McKittrick
- Department of Internal Medicine, University of Kansas Medical Center, Overland Park, KS, USA
| | - Robert Pluenneke
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, MO, USA
| | - Sheshadri Madhusudhana
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Larry Beck
- Tammy Walker Cancer Center, Salina Regional Health Center, Salina, KS, USA
| | - Anuj Shrestha
- Richard & Annette Bloch Cancer Center, Truman Medical Center, Kansas City, MO, USA
| | - Larry Corum
- Olathe Cancer Care, Olathe Medical Center, Olathe, KS, USA
| | - Mark Marsico
- Department of Pharmacoepidemiology/Oncology, Merck & Co., Inc, Kenilworth, NJ, USA
| | - Shane R Stecklein
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Andrew K Godwin
- University of Kansas Cancer Center, Kansas City, KS, USA.,Department of Pathology & Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Qamar J Khan
- Department of Internal Medicine, University of Kansas Medical Center, Westwood, KS, USA
| | - Priyanka Sharma
- Department of Internal Medicine, University of Kansas Medical Center, Westwood, KS, USA.
| |
Collapse
|
20
|
Rakha EA, Chmielik E, Schmitt FC, Tan PH, Quinn CM, Gallagy G. Assessment of Predictive Biomarkers in Breast Cancer: Challenges and Updates. Pathobiology 2022; 89:263-277. [PMID: 35728576 DOI: 10.1159/000525092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 05/09/2022] [Indexed: 11/19/2022] Open
Abstract
The management of patients with breast cancer (BC) relies on the assessment of a defined set of well-established prognostic and predictive markers. Despite overlap, prognostic markers are used to assess the risk of recurrence and the likely benefit of systemic therapy, whereas predictive markers are used to determine the type of systemic therapy to be offered to an individual patient. In this review, we provide an update and present some challenges in the assessment of the main BC-specific molecular predictive markers, namely hormone receptors (oestrogen receptor [ER] and progesterone receptor [PR]), human epidermal growth factor receptor 2 (HER2), and KI67. As the main platform for assessing these markers in BC is immunohistochemistry (IHC), we address the cut-off values used to define positivity, the ER-low subgroup, the existence and significance of the ER-/PR+ phenotype, the use of PR in routine practice, and the role of hormone receptors in ductal carcinoma in situ. We discuss the newly introduced HER2-low class of BC and the clinical/biological difference between different HER2 groups (e.g., HER2 IHC score 3+ BCs vs. those with a HER2 IHC score 2+ with HER2 gene amplification). The review concludes with an update on the applications of KI67 assessment in BC and observations on the role of immune checkpoint identification in BC.
Collapse
Affiliation(s)
- Emad A Rakha
- Department of Histopathology, School of Medicine, The University of Nottingham, and Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Ewa Chmielik
- Tumor Pathology Department, Maria Sklodowska-Curie Memorial National Research Institute of Oncology, Gliwice, Poland
| | - Fernando C Schmitt
- Institute of Molecular Pathology and Immunology (IPATIMUP) and Medical Faculty, University of Porto, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,RISE (Health Research Network) @ CINTESIS (Center for Health Technology and Services Research), Porto, Portugal
| | - Puay Hoon Tan
- Department of Pathology, Singapore General Hospital, Singapore, Singapore
| | - Cecily M Quinn
- Department of Histopathology, BreastCheck, Irish National Breast Screening Programme and St. Vincent's University Hospital, Dublin and University College, Dublin, Ireland
| | - Grace Gallagy
- Discipline of Pathology, School of Medicine, Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| |
Collapse
|
21
|
Luo C, Zhong X, Fan Y, Wu Y, Zheng H, Luo T. Clinical characteristics and survival outcome of patients with estrogen receptor low positive breast cancer. Breast 2022; 63:24-28. [PMID: 35279509 PMCID: PMC8920919 DOI: 10.1016/j.breast.2022.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 02/19/2022] [Accepted: 03/07/2022] [Indexed: 02/05/2023] Open
Abstract
Background The benefit of endocrine therapy for patients with estrogen receptor (ER)-low (1%–10%) positive breast cancer is a matter for debate. We aimed to compare the clinical characteristics and survival outcome of ER-low patients with ER-high (>10%) positive patients and ER-negative patients. Methods From the breast cancer database of our institution, we identified 5466 patients with known ER status who were diagnosed with early-stage breast cancer between January 2008 and December 2016. Variables associated with initiation of endocrine therapy were identified using multivariate logistic regression model. According to ER status, all patients were classified into ER-low (1%–10%), ER-high (>10%) and ER-negative subgroups. Fine and Gray competing risks regression was performed to compare the survival outcome of three subgroups. Results Age at diagnosis, ER status and progesterone receptor (PR) status were identified as correlates of initiation of endocrine therapy. ER-low patients were more likely to have advanced, PR-negative, human epidermal growth factor receptor 2 (HER2)-positive or grade Ⅲ disease compared to ER-high patients. Similar to ER-negative patients, ER-low patients presented increased rate of locoregional recurrence (LRR), distant recurrence (DR) and breast cancer mortality (BCM) than ER-high patients. Endocrine therapy showed nonsignificant trends toward lower LRR, DR and BCM in ER-low patients. Conclusion Similar to ER-negative patients, ER-low patients had more aggressive clinical characteristics and worse survival outcome than ER-high patients. ER-low patients appeared to benefit less from endocrine therapy. Randomized studies are needed to further explore the endocrine responsiveness of ER-low patients. Age at diagnosis, ER status and PR status were associated with initiation of endocrine therapy. ER-low patients had more aggressive clinical characteristics and worse survival outcome than ER-high patients. ER-low patients appeared to benefit less from endocrine therapy than ER-high patients.
Collapse
Affiliation(s)
- Chuanxu Luo
- Laboratory of Molecular Diagnosis of Cancer & Breast Medical Oncology, Clinical Research Center for Breast,West China Hospital, Sichuan University, Chengdu, China
| | - Xiaorong Zhong
- Laboratory of Molecular Diagnosis of Cancer & Breast Medical Oncology, Clinical Research Center for Breast,West China Hospital, Sichuan University, Chengdu, China
| | - Yu Fan
- Laboratory of Molecular Diagnosis of Cancer & Breast Medical Oncology, Clinical Research Center for Breast,West China Hospital, Sichuan University, Chengdu, China
| | - Yanqi Wu
- Laboratory of Molecular Diagnosis of Cancer & Breast Medical Oncology, Clinical Research Center for Breast,West China Hospital, Sichuan University, Chengdu, China
| | - Hong Zheng
- Laboratory of Molecular Diagnosis of Cancer & Breast Medical Oncology, Clinical Research Center for Breast,West China Hospital, Sichuan University, Chengdu, China
| | - Ting Luo
- Department of Head, Neck and Mammary Gland Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China.
| |
Collapse
|
22
|
Gong C, Cheng Z, Yang Y, Shen J, Zhu Y, Ling L, Lin W, Yu Z, Li Z, Tan W, Zheng C, Zheng W, Zhong J, Zhang X, Zeng Y, Liu Q, Huang RS, Komorowski AL, Yang ES, Bertucci F, Ricci F, Orlandi A, Franceschini G, Takabe K, Klimberg S, Ishii N, Toss A, Tan MP, Cherian MA, Song E. A 10-miRNA risk score-based prediction model for pathological complete response to neoadjuvant chemotherapy in hormone receptor-positive breast cancer. SCIENCE CHINA. LIFE SCIENCES 2022; 65:2205-2217. [PMID: 35579777 DOI: 10.1007/s11427-022-2104-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/23/2022] [Indexed: 12/21/2022]
Abstract
Patients with hormone receptor (HR)-positive tumors breast cancer usually experience a relatively low pathological complete response (pCR) to neoadjuvant chemotherapy (NAC). Here, we derived a 10-microRNA risk score (10-miRNA RS)-based model with better performance in the prediction of pCR and validated its relation with the disease-free survival (DFS) in 755 HR-positive breast cancer patients (273, 265, and 217 in the training, internal, and external validation sets, respectively). This model, presented as a nomogram, included four parameters: the 10-miRNA RS found in our previous study, progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2) status, and volume transfer constant (Ktrans). Favorable calibration and discrimination of 10-miRNA RS-based model with areas under the curve (AUC) of 0.865, 0.811, and 0.804 were shown in the training, internal, and external validation sets, respectively. Patients who have higher nomogram score (>92.2) with NAC treatment would have longer DFS (hazard ratio=0.57; 95%CI: 0.39-0.83; P=0.004). In summary, our data showed the 10-miRNA RS-based model could precisely identify more patients who can attain pCR to NAC, which may help clinicians formulate the personalized initial treatment strategy and consequently achieves better clinical prognosis for patients with HR-positive breast cancer.
Collapse
Affiliation(s)
- Chang Gong
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangdong-Hong Kong Joint Laboratory for RNA Medicine, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
| | - Ziliang Cheng
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
| | - Yaping Yang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangdong-Hong Kong Joint Laboratory for RNA Medicine, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
| | - Jun Shen
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
| | - Yingying Zhu
- Clinical Research Design Division, Clinical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
| | - Li Ling
- Clinical Research Design Division, Clinical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China.,Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, China
| | - Wanyi Lin
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangdong-Hong Kong Joint Laboratory for RNA Medicine, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
| | - Zhigang Yu
- Department of Breast Surgery, the Second Affiliated Hospital, Shandong University, Jinan, 250033, China
| | - Zhihua Li
- Department of Breast Surgery, Key Laboratory of Breast Diseases, Third Hospital of Nanchang, Nanchang, 330009, China
| | - Weige Tan
- Department of Breast Surgery, the First Affiliated Hospital, Guangzhou Medical University, Guangzhou, 510120, China
| | - Chushan Zheng
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
| | - Wenbo Zheng
- Department of Breast Surgery, the First Affiliated Hospital, Guangzhou Medical University, Guangzhou, 510120, China
| | - Jiajie Zhong
- Department of Pathology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
| | - Xiang Zhang
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
| | - Yunjie Zeng
- Department of Pathology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
| | - Qiang Liu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangdong-Hong Kong Joint Laboratory for RNA Medicine, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
| | - R Stephanie Huang
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Andrzej L Komorowski
- Department of Surgery, College of Medicine, University of Rzeszów, Rzeszów, 35-959, Poland
| | - Eddy S Yang
- Department of Radiation Oncology, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - François Bertucci
- Laboratoty of Predictive Oncology, Institut Paoli-Calmettes, Centre de Recherche en Cancérologie de Marseille, INSERM UMR1068, CNRS UMR725, Marseille, France
| | - Francesco Ricci
- Department of Drug Development and Innovation(D3i), Institut Curie, Paris, 75005, France
| | - Armando Orlandi
- Comprehensive Cancer Center, UOC di Oncologia Medica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, 00168, Italy
| | - Gianluca Franceschini
- Multidisciplinary Breast Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, 00168, Italy
| | - Kazuaki Takabe
- Breast Surgery, Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Suzanne Klimberg
- Department of Surgery, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Naohiro Ishii
- Department of Plastic and Reconstructive Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 329-2763, Japan
| | - Angela Toss
- Department of Oncology and Hematology, University Hospital of Modena, Modena, 41124, Italy
| | - Mona P Tan
- MammoCare: Breast Clinic and Surgery in Singapore, Singapore, 228510, Singapore
| | - Mathew A Cherian
- The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH, 43210, USA
| | - Erwei Song
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangdong-Hong Kong Joint Laboratory for RNA Medicine, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China.
| |
Collapse
|
23
|
de Oliveira VM, Dias MMG, Avelino TM, Videira NB, da Silva FB, Doratioto TR, Whitford PC, Leite VBP, Figueira ACM. pH and the Breast Cancer Recurrent Mutation D538G Affect the Process of Activation of Estrogen Receptor α. Biochemistry 2022; 61:455-463. [PMID: 35238537 DOI: 10.1021/acs.biochem.1c00806] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Estrogen receptor α (ERα) is a regulatory protein that can access a set of distinct structural configurations. ERα undergoes extensive remodeling as it interacts with different agonists and antagonists, as well as transcription activation and repression factors. Moreover, breast cancer tumors resistant to hormone therapy have been associated with the imbalance between the active and inactive ERα states. Cancer-activating mutations in ERα play a crucial role in this imbalance and can promote the progression of cancer. However, the rate of this progression can also be increased by dysregulated pH in the tumor microenvironment. Many molecular aspects of the process of activation of ERα that can be affected by these pH changes and mutations are still unclear. Thus, we applied computational and experimental techniques to explore the activation process dynamics of ER for environments with different pHs and in the presence of one of the most recurrent cancer-activating mutations, D538G. Our results indicated that the effect of the pH increase associated with the D538G mutation promoted a robust stabilization of the active state of ER. We were also able to determine the main protein regions that have the most potential to influence the activation process under different pH conditions, which may provide targets of future therapeutics for the treatment of hormone-resistant breast cancer tumors. Finally, the approach used here can be applied for proteins associated with the proliferation of other cancer types, which can also have their function affected by small pH changes.
Collapse
Affiliation(s)
- Vinícius M de Oliveira
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, LNBio/CNPEM, Campinas 13083-970, SP, Brazil
| | - Marieli M G Dias
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, LNBio/CNPEM, Campinas 13083-970, SP, Brazil
| | - Thayná M Avelino
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, LNBio/CNPEM, Campinas 13083-970, SP, Brazil
| | - Natália B Videira
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, LNBio/CNPEM, Campinas 13083-970, SP, Brazil
| | - Fernando B da Silva
- Department of Physics, São Paulo State University (UNESP), Institute of Biosciences, Humanities and Exact Sciences, São José do Rio Preto 01140-070, SP, Brazil
| | - Tábata R Doratioto
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, LNBio/CNPEM, Campinas 13083-970, SP, Brazil
| | - Paul C Whitford
- Department of Physics, Northeastern University, Boston, Massachusetts 02115, United States
| | - Vitor B P Leite
- Department of Physics, São Paulo State University (UNESP), Institute of Biosciences, Humanities and Exact Sciences, São José do Rio Preto 01140-070, SP, Brazil
| | - Ana Carolina M Figueira
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, LNBio/CNPEM, Campinas 13083-970, SP, Brazil
| |
Collapse
|
24
|
Kreidieh F, Sadek RF, Zhang LF, Gopal A, Blaize JP, Yashar D, Patel R, Patel HS, Tang SC, Abdul Sater H. Validity of 1% Hormonal Receptor Positivity Cutoff by the ASCO/College of American Pathologists Guidelines at the Georgia Cancer Center. JCO Precis Oncol 2022; 6:e2100201. [PMID: 35201853 PMCID: PMC8974571 DOI: 10.1200/po.21.00201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Treatment of breast cancer (BC) with borderline or low (1%-9%) estrogen and progesterone expression remains controversial, with recent data disputing ASCO/College of American Pathologists 2010 guidelines that lowered the threshold of receptor positivity from 10% to 1%. The objective of this retrospective study was to validate these guidelines at the Georgia Cancer Center with a high percentage of Black race. METHODS All female patients with invasive BC diagnosed between 2005 and 2010 at the Georgia Cancer Center were chart reviewed up to an 11-year follow-up with data cutoff at 2016. We used Cox regression to explore survival among three hormonal status (HS) groups (< 1%, 1%-9%, and ≥ 10%) adjusting for all known BC clinicopathologic variables. Fisher's exact test was used to evaluate response to endocrine therapy (ET). RESULTS Among 431 patients with mean age 59 years, 24.75% had HS < 1%, 17.5% HS 1%-9%, and 57.75% HS ≥ 10%. Race was 43.75% Black and 54% White. Disease stages were early (I-IIIA) in 84.4% and advanced (IIIB-IV) in 15.56%. Mortality in HS < 1% was significantly higher than that in HS ≥ 10% (hazard ratio [HR]: 1.8; 95% CI, 1.07 to 3.02), whereas no significant mortality difference between HS 1%-9% and HS ≥ 10% (HR: 1.05; 95% CI, 0.48 to 2.30) was observed. ET was protective, and treated patients had higher predicted survival than untreated patients in the 1%-9% group (HR: 0.10; 95% CI, 0.01 to 0.85). There was no significant mortality difference between ET-treated HS 1%-9% and ≥ 10% groups. CONCLUSION One percent cutoff predicted superior survival on treatment with ET compared with the other groups, and HS as low as 1%-9% was equiprognostic to HS ≥ 10%. Whether other factors such as lymphovascular invasion, grade, and other parameters change the behavior of the 1%-9% HS group remains to be explored.
Collapse
Affiliation(s)
- Firas Kreidieh
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Ramses F Sadek
- Augusta University/Medical College of Georgia, Augusta, GA
| | - Li Fang Zhang
- Augusta University/Medical College of Georgia, Augusta, GA
| | - Aaron Gopal
- Augusta University/Medical College of Georgia, Augusta, GA
| | | | | | - Reena Patel
- Medical University of South Carolina, Charleston, SC
| | | | - Shou-Ching Tang
- University of Mississippi Cancer Center and Research Institute, Jackson, MS
| | | |
Collapse
|
25
|
Prognostic Factors Effective on Survival in Unifocal Borderline Luminal B HER2-Negative and Triple-Negative Breast Cancers: a Cross-Sectional Study. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03294-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
26
|
Updates on breast biomarkers. Virchows Arch 2022; 480:163-176. [PMID: 35029776 DOI: 10.1007/s00428-022-03267-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/13/2021] [Accepted: 12/30/2021] [Indexed: 12/22/2022]
Abstract
Recent advancements in breast cancer treatment have ushered in a new era of precision medicine. Novel trials have led to the approval of a growing list of personalized therapies and corresponding biomarkers. These advancements have shifted the pathologist's practice into a leading role in the management breast cancer. Understanding the complex algorithms and diagnostic modalities used to assess predictive and prognostic biomarkers is central for quality oncology care. ER and HER2 subcategorize breast cancers into treatment groups under which different biomarkers and therapies are indicated, while they also serve as predictive biomarkers for specific targeted treatments. This review will cover the evolution and latest updates of the CAP/ASCO guidelines relevant to these two important biomarkers in breast cancer. Still evolving concepts such as HER2 heterogeneity, HER2 "low," and HER2-mutated cancers have the potential to continue to change HER2 testing in breast cancers. In addition to ER and HER2, biomarkers used in specific clinical scenarios will be covered. In early-stage ER-positive/HER2-negative disease, multi-gene expression panels (such as OncotypeDX) have emerged as the new standard biomarker when determining if chemotherapy should be added to endocrine therapy. In the more aggressive ER-negative/HER2-positive or triple negative early-stage breast cancers, response to neoadjuvant therapy has proved to be a useful biomarker to help determine if additional therapy should be added for patients with an incomplete response. Ki67 has also recently emerged as a marker that can be used to identify the highest risk ER-positive and HER2-negative cancers if considering adding a cell cycle inhibitor (abemaciclib) to endocrine therapy. Importantly, in the metastatic setting, numerous predictive biomarkers have emerged, including recommendations for germline BRCA mutation testing for all metastatic patients (to determine if PARP inhibitor therapy is an option) and other ER-/HER2-dependent biomarkers such as PD-L1 (for potential immunotherapy in triple negative patients) and PIK3CA mutation status (for potential PI3K inhibitor therapy in ER-positive metastatic patients). Other less common biomarkers of targeted therapy options (e.g., MSI/MMR, TMB, NTRK) as well as comprehensive genomic profiling to identify uncommon targets are also available in the metastatic setting to determine additional treatment options.
Collapse
|
27
|
Shiino S, Ball G, Syed BM, Kurozumi S, Green AR, Tsuda H, Takayama S, Suto A, Rakha EA. Prognostic significance of receptor expression discordance between primary and recurrent breast cancers: a meta-analysis. Breast Cancer Res Treat 2022; 191:1-14. [PMID: 34613502 PMCID: PMC8758639 DOI: 10.1007/s10549-021-06390-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 09/06/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE This meta-analysis aimed to investigate whether receptor (estrogen receptor [ER], progesterone receptor [PR], and human epidermal growth factor receptor 2 [HER2]) discordances between primary and recurrent breast cancers affect patients' survival. METHODS Search terms contained ER, PR, and HER2 status details in both primary and recurrent tumors (local recurrence or distant metastasis) in addition to survival outcome data (overall survival [OS] or post-recurrence survival [PRS]). RESULTS Loss of ER or PR in recurrent tumors was significantly associated with shorter OS as compared with receptor-positive concordance (hazard ratio [HR], 1.67; 95% confidence interval [% CI] 1.37-2.04; p < 0.00001 and HR, 1.45; 95% CI 1.21-1.75; p < 0.0001, respectively). Similar trends were observed in groups with only distant metastasis. Gain of ER was a significant predictor of longer PRS as compared with receptor-negative concordance (HR, 0.76; 95% CI 0.59-0.97; p = 0.03). Gain of PR was not a significant predictor of longer survival compared with receptor-negative concordance, but it could be related to better OS at distant metastasis. Both HER2 of loss and gain could be related to poor outcomes. CONCLUSION This meta-analysis showed that receptor conversion in recurrent tumors may affect patient survival as compared with receptor concordance.
Collapse
Affiliation(s)
- Sho Shiino
- Division of Cancer and Stem Cells, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Breast Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Graham Ball
- School of Science & Technology, John Van Geest Cancer Research Centre, Nottingham Trent University, Clifton Campus, Clifton Lane, Nottingham, UK
| | - Binafsha M Syed
- Head of Clinical Research Division, Medical Research Centre, Liaquat University of Medical & Health Sciences, Jamshoro, Pakistan
| | - Sasagu Kurozumi
- Department of Breast Surgery, International University of Health and Welfare, Narita, Japan
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Andrew R Green
- Division of Cancer and Stem Cells, School of Medicine, University of Nottingham, Nottingham, UK
| | - Hitoshi Tsuda
- Department of Basic Pathology, National Defense Medical College Hospital, Tokorozawa, Japan
| | - Shin Takayama
- Department of Breast Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Akihiko Suto
- Department of Breast Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Emad A Rakha
- Division of Cancer and Stem Cells, School of Medicine, University of Nottingham, Nottingham, UK.
- Department of Histopathology, Nottingham University Hospital NHS Trust, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB, UK.
| |
Collapse
|
28
|
Yoon KH, Park Y, Kang E, Kim EK, Kim JH, Kim SH, Suh KJ, Kim SM, Jang M, Yun BL, Park SY, Shin HC. Effect of Estrogen Receptor Expression Level and Hormonal Therapy on Prognosis of Early Breast Cancer. Cancer Res Treat 2021; 54:1081-1090. [PMID: 34793665 PMCID: PMC9582488 DOI: 10.4143/crt.2021.890] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/15/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose Estrogen receptor (ER) expression in breast cancer plays an essential role in carcinogenesis and disease progression. Recently, tumors with low level (1%–10%) of ER expression have been separately defined as ER low positive (ERlow). It is suggested that ERlow tumors might be morphologically and behaviorally different from tumors with high ER expression (ERhigh). Materials and Methods Retrospective analysis of a prospective cohort database was performed. Patients who underwent curative surgery for early breast cancer and had available medical records were included for analysis. Difference in clinicopathological characteristics, endocrine responsiveness and five-year recurrence-free survival was evaluated between different ER subgroups (ERhigh, ERlow, and ER-negative [ER−]). Results A total of 2,162 breast cancer patients were included in the analysis, Tis and T1 stage. Among them, 1,654 (76.5%) were ERhigh, 54 (2.5%) were ERlow, and 454 (21.0%) were ER− patients. ERlow cases were associated with smaller size, higher histologic grade, positive human epidermal growth factor receptor 2, negative progesterone receptor, and higher Ki-67 expression. Recurrence rate was highest in ER− tumors and was inversely proportional to ER expression. Recurrence-free survival was not affected by hormonal therapy in the ERlow group (p=0.418). Conclusion ERlow breast cancer showed distinct clinicopathological features. ERlow tumors seemed to have higher recurrence rates compared to ERhigh tumors, and they showed no significant benefit from hormonal therapy. Future large scale prospective studies are necessary to validate the treatment options for ERlow breast cancer.
Collapse
Affiliation(s)
- Kyung-Hwak Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yeshong Park
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Eunyoung Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Eun-Kyu Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jee Hyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Se Hyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Koung Jin Suh
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sun Mi Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Mijung Jang
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Bo La Yun
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - So Yeon Park
- Department of Pathology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hee-Chul Shin
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| |
Collapse
|
29
|
Tecalco-Cruz AC, Zepeda-Cervantes J, Ramírez-Jarquín JO, Rojas-Ochoa A. Proteolysis-targeting chimeras and their implications in breast cancer. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2021; 2:496-510. [PMID: 36046115 PMCID: PMC9400758 DOI: 10.37349/etat.2021.00060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/12/2021] [Indexed: 12/14/2022] Open
Abstract
Breast cancer (BC) is a highly heterogeneous neoplasm of the mammary tissue, causing the deaths of a large number of women worldwide. Nearly 70% and 20% of BC cases are estrogen receptor alpha positive (ERα+) and human epidermal growth factor receptor 2-positive (HER2+), respectively; therefore, ER and HER2 targeted therapies have been employed in BC treatment. However, resistance to these therapies has been reported, indicating a need for developing novel therapeutic strategies. Proteolysis-targeting chimeras (PROTACs) are new, promising therapeutic tools designed with a bimodular structure: one module allows specific binding to target proteins, and the other module allows efficient degradation of these target proteins. In this paper, PROTACs and their potential in controlling the progression of ERα and HER2+ BC are discussed.
Collapse
Affiliation(s)
- Angeles C. Tecalco-Cruz
- Posgrado en Ciencias Genómicas, Universidad Autónoma de la Ciudad de México (UACM), CDMX, Mexico City 03100, Mexico
| | - Jesús Zepeda-Cervantes
- Departamento de Microbiología e Inmunología, Facultad de Medicina Veterinaria y Zootecnia, Universidad Nacional Autónoma de México (UNAM), CDMX, Mexico City 04510, Mexico
| | - Josué O. Ramírez-Jarquín
- Instituto de Fisiología Celular, Universidad Nacional Autónoma de México (UNAM), CDMX, Mexico City 04500, Mexico
| | | |
Collapse
|
30
|
The prognostic and predictive impact of low estrogen receptor expression in early breast cancer: a systematic review and meta-analysis. ESMO Open 2021; 6:100289. [PMID: 34678571 PMCID: PMC8531568 DOI: 10.1016/j.esmoop.2021.100289] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 01/21/2023] Open
Abstract
Introduction Traditionally, estrogen receptor (ER)-positive breast cancer has been defined as tumors with ≥1% positive for ER. The updated American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) guidelines recommend that tumors with ER expression of 1%-10% should be classified as ER-low-positive, recognizing the limited clinical evidence on the prognostic and predictive role of low ER expression. We aimed to investigate the predictive role of ER-low expression to neoadjuvant chemotherapy (NeoCT) and the prognostic significance of ER-low expressing breast tumors compared with ER-positive or ER-negative breast tumors. Methods A meta-analysis was conducted using the Meta-analyses Of Observational Studies in Epidemiology (MOOSE) guidelines and eligible articles were identified on PubMed and ISI Web of Science databases. The primary outcome was pathologic complete response and secondary outcomes were disease-free survival (DFS) and overall survival (OS). Twelve retrospective cohort studies were included in the meta-analysis. NeoCT resulted in higher pathologic complete response among patients with ER-low expression compared with ER-positive and comparable to ER-negative. Patients with ER-low breast cancer had a statistically significant worse DFS and OS compared with patients with ER-positive breast cancer, whereas no difference in DFS or OS was observed between ER-low and ER-negative subgroups. Discussion The current evidence suggests that ER-low breast cancer has a more similar outcome to ER-negative than to ER-positive breast cancer in terms of DFS and OS. ER-low expression seems also to have a predictive role regarding NeoCT. Considering the certainty of current evidence categorized as low to moderate, our results urge the need for well-designed prospective studies investigating the molecular background and the most appropriate treatment strategy for ER-low expressing breast cancer. The predictive and prognostic roles of estrogen receptor (ER)-low breast cancer have been studied in this meta-analysis. ER-low expression was associated with higher pathologic complete response after NeoCT compared with ER-positive. Both disease-free and overall survival were comparable between ER-low breast cancer and ER-negative breast cancer.
Collapse
|
31
|
Caselli E, Pelliccia C, Teti V, Bellezza G, Mandarano M, Ferri I, Hartmann K, Laible M, Sahin U, Varga Z, Lupi C, Stracci F, Sidoni A. Looking for more reliable biomarkers in breast cancer: Comparison between routine methods and RT-qPCR. PLoS One 2021; 16:e0255580. [PMID: 34555047 PMCID: PMC8460001 DOI: 10.1371/journal.pone.0255580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 07/19/2021] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Decades of quality control efforts have raised the standards of immunohistochemistry (IHC), the principle method used for biomarker testing in breast cancer; however, computational pathology and reverse transcription quantitative PCR (RT-qPCR) may also hold promise for additional substantial improvements. METHODS Herein, we investigated discrepancies in the assessment of estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2) and marker of proliferation Ki67 comparing routinely obtained IHC (and FISH) data (ORI) with the results of manual (REV) and semi-automated (DIA) re-evaluation of the original IHC slides and then with RNA expression data from the same tissue block using the MammaTyper® (MT) gene expression assay. RESULTS Correlation for ER and PR was high between ORI IHC and the other three study methods (REV, DIA and RT-qPCR). For HER2, 10 out of 96 discrepant cases can be detected between ORI and REV that involved at least one call in the equivocal category (except for one case). For Ki67, 22 (29.1%) cases were categorized differently by either REV alone (n = 17), DIA alone (n = 15) or both (n = 10) and 28 cases (29.2%) for RT-qPCR. Most of the discrepant Ki67 cases changed from low to high between the original and following assessment and belonged to the intermediate Ki67 expression range (between 9 and 30%). CONCLUSIONS Determination of the breast cancer biomarkers ER, PR, HER2 and Ki67 at the mRNA level shows high degree of correlation with IHC and compares well with correlations between original with subsequent independent manual or semi-automated IHC assessments. The use of methods with wider dynamic range and higher reproducibility such as RT-qPCR may offer more precise assessment of endocrine responsiveness, improve Ki67 standardization and help resolve HER2 cases that remain equivocal or ambiguous by IHC/FISH. In summary, our findings seem to configure RT-qPCR as a complementary method to be used in cases of either equivocal results or presenting, at the traditional determination assays, biomarkers expressions close to the cut-off values.
Collapse
Affiliation(s)
- Emanuele Caselli
- Department of Medicine and Surgery, Section of Anatomic Pathology and Histology, Medical School, University of Perugia, Perugia, Italy
| | - Cristina Pelliccia
- Department of Medicine and Surgery, Section of Anatomic Pathology and Histology, Medical School, University of Perugia, Perugia, Italy
| | - Valeria Teti
- Department of Medicine and Surgery, Section of Anatomic Pathology and Histology, Medical School, University of Perugia, Perugia, Italy
| | - Guido Bellezza
- Department of Medicine and Surgery, Section of Anatomic Pathology and Histology, Medical School, University of Perugia, Perugia, Italy
| | - Martina Mandarano
- Department of Medicine and Surgery, Section of Anatomic Pathology and Histology, Medical School, University of Perugia, Perugia, Italy
| | - Ivana Ferri
- Department of Medicine and Surgery, Section of Anatomic Pathology and Histology, Medical School, University of Perugia, Perugia, Italy
| | | | | | - Ugur Sahin
- BioNTech Diagnostics GmbH, Mainz, Germany
| | - Zsuzsanna Varga
- Institute for Pathology and Molecular Pathology, Universitätsspital Zürich, Zürich, Switzerland
| | | | - Fabrizio Stracci
- Umbria Cancer Registry, Perugia, Italy
- Department of Medicine and Surgery, Section of Public Health, University of Perugia, Perugia, Italy
| | - Angelo Sidoni
- Department of Medicine and Surgery, Section of Anatomic Pathology and Histology, Medical School, University of Perugia, Perugia, Italy
| |
Collapse
|
32
|
Erber R, Hartmann A, Fasching PA, Ruebner M, Stöhr R, Beckmann MW, Zentgraf M, Popp V, Weidler J, Simon I, Becker S, Huebner H, Fischer J, Guerini Rocco E, Viale G, Cayre A, Penault-Llorca F, Caniego Casas T, Pérez-Miés B, Palacios J, Jank P, Denkert C, Khoury L, Mairinger T, Ferrazzi F. Reproducibility of mRNA-Based Testing of ESR1, PGR, ERBB2, and MKI67 Expression in Invasive Breast Cancer-A Europe-Wide External Quality Assessment. Cancers (Basel) 2021; 13:cancers13184718. [PMID: 34572945 PMCID: PMC8470348 DOI: 10.3390/cancers13184718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/08/2021] [Indexed: 12/25/2022] Open
Abstract
Simple Summary Four biomarkers [estrogen receptor (ER), progesterone receptor (PgR), Ki-67, and HER2], are used to stratify breast cancer (BC) into subtypes predictive of therapy response. In a Europe-wide external quality assessment, we compared performance of an mRNA-based method [Xpert® Breast Cancer STRAT4 (CE-IVD)] for determining ESR1, PGR, ERBB2, and MKI67 expression against the gold standard [immunohistochemistry (IHC)/HER2 in situ hybridization (ISH)]. The coordinating center (CC) and five European laboratories tested ten breast cancer samples. STRAT4 binary (positive or negative) results of each marker were compared with the gold standard. ESR1 and ERBB2 mRNA results were concordant with IHC/ISH in all single analyses. In contrast, PGR and MKI67 results were discordant in a few cases, which had STRAT4 expression values close to assay cut-offs and immunohistochemically presented heterogeneous low positive PgR and heterogeneous Ki-67. STRAT4 assay may be a reproducible method. However, cases with expression values close to cut-offs should be carefully reviewed. Abstract Estrogen receptor (ER), progesterone receptor (PgR), Ki-67, and HER2 immunohistochemistry (IHC) together with HER2 in situ hybridization (ISH) are utilized to classify invasive breast cancer (IBC) into predictive molecular subtypes. As IHC evaluation may be hampered by analytical errors, gene expression assays could offer a reliable alternative. In this first Europe-wide external quality assessment (EQA) study, we investigated performance of mRNA-based Xpert® Breast Cancer STRAT4 (CE-IVD) in five European laboratories. The cohort comprised ten pre-therapy IBC core biopsies diagnosed in the coordinating center (CC). STRAT4 binary (positive or negative) mRNA results of each marker (ESR1, PGR, ERBB2, MKI67) were compared with the gold standard IHC/ISH performed by the CC. Sensitivity, specificity, and accuracy of ESR1 and ERBB2 mRNA were 100% for all samples. In contrast, PGR expression was falsely negative for one case by two sites and MKI67 falsely negative for two cases (respectively by four and one sites). These cases had STRAT4 expression values close to assay cut-offs and immunohistochemically presented heterogeneous low positive PgR and heterogeneous Ki-67. Our EQA shows that STRAT4 mRNA assay may be a reproducible method to evaluate ER, PgR, HER2, and Ki-67 status. However, cases with expression values close to assay cut-offs should be carefully reviewed.
Collapse
Affiliation(s)
- Ramona Erber
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (R.S.); (M.Z.); (V.P.); (F.F.)
- Correspondence: (R.E.); (A.H.); Tel.: +49-9131-85-43634 (R.E.); +49-9131-85-22287 (A.H.)
| | - Arndt Hartmann
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (R.S.); (M.Z.); (V.P.); (F.F.)
- Correspondence: (R.E.); (A.H.); Tel.: +49-9131-85-43634 (R.E.); +49-9131-85-22287 (A.H.)
| | - Peter Andreas Fasching
- Department of Gynecology and Obstetrics, University Hospital Erlangen, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (P.A.F.); (M.R.); (M.W.B.); (H.H.)
| | - Matthias Ruebner
- Department of Gynecology and Obstetrics, University Hospital Erlangen, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (P.A.F.); (M.R.); (M.W.B.); (H.H.)
| | - Robert Stöhr
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (R.S.); (M.Z.); (V.P.); (F.F.)
| | - Matthias Wilhelm Beckmann
- Department of Gynecology and Obstetrics, University Hospital Erlangen, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (P.A.F.); (M.R.); (M.W.B.); (H.H.)
| | - Miriam Zentgraf
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (R.S.); (M.Z.); (V.P.); (F.F.)
| | - Verena Popp
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (R.S.); (M.Z.); (V.P.); (F.F.)
| | - Jodi Weidler
- Cepheid, Department of Medical and Scientific Affairs and Strategy, Oncology, 904 Caribbean Drive, Sunnyvale, CA 94089, USA; (J.W.); (I.S.); (S.B.)
| | - Iris Simon
- Cepheid, Department of Medical and Scientific Affairs and Strategy, Oncology, 904 Caribbean Drive, Sunnyvale, CA 94089, USA; (J.W.); (I.S.); (S.B.)
| | - Steffi Becker
- Cepheid, Department of Medical and Scientific Affairs and Strategy, Oncology, 904 Caribbean Drive, Sunnyvale, CA 94089, USA; (J.W.); (I.S.); (S.B.)
| | - Hanna Huebner
- Department of Gynecology and Obstetrics, University Hospital Erlangen, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (P.A.F.); (M.R.); (M.W.B.); (H.H.)
| | - Josephine Fischer
- Qualitätssicherungs-Initiative Pathologie QuIP GmbH, 10117 Berlin, Germany;
| | - Elena Guerini Rocco
- Department of Pathology and Laboratory Medicine, IEO, European Institute of Oncology, IRCCS, 20141 Milan, Italy; (E.G.R.); (G.V.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Giuseppe Viale
- Department of Pathology and Laboratory Medicine, IEO, European Institute of Oncology, IRCCS, 20141 Milan, Italy; (E.G.R.); (G.V.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Anne Cayre
- Centre Jean Perrin, Department of Pathology and Clermont Auvergne University, INSERM, U1240, “Imagerie Moléculaire et Stratégies Théranostiques”, F-63011 Clermont Ferrand, France; (A.C.); (F.P.-L.)
| | - Frederique Penault-Llorca
- Centre Jean Perrin, Department of Pathology and Clermont Auvergne University, INSERM, U1240, “Imagerie Moléculaire et Stratégies Théranostiques”, F-63011 Clermont Ferrand, France; (A.C.); (F.P.-L.)
| | - Tamara Caniego Casas
- Instituto Ramón y Cajal de Investigación Sanitaria, 28034 Madrid, Spain; (T.C.C.); (B.P.-M.); (J.P.)
- CIBER-ONC, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Belén Pérez-Miés
- Instituto Ramón y Cajal de Investigación Sanitaria, 28034 Madrid, Spain; (T.C.C.); (B.P.-M.); (J.P.)
- CIBER-ONC, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Department of Pathology, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
- Facultad de Medicina, Universidad de Alcalá de Henares, 28871 Madrid, Spain
| | - José Palacios
- Instituto Ramón y Cajal de Investigación Sanitaria, 28034 Madrid, Spain; (T.C.C.); (B.P.-M.); (J.P.)
- CIBER-ONC, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Department of Pathology, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
- Facultad de Medicina, Universidad de Alcalá de Henares, 28871 Madrid, Spain
| | - Paul Jank
- Institute of Pathology, UKGM—University Hospital Marburg, Philipps-University Marburg, 35043 Marburg, Germany; (P.J.); (C.D.)
| | - Carsten Denkert
- Institute of Pathology, UKGM—University Hospital Marburg, Philipps-University Marburg, 35043 Marburg, Germany; (P.J.); (C.D.)
| | - Lina Khoury
- MVZ Helios Hospital Emil von Behring GmbH, 14165 Berlin, Germany; (L.K.); (T.M.)
| | - Thomas Mairinger
- MVZ Helios Hospital Emil von Behring GmbH, 14165 Berlin, Germany; (L.K.); (T.M.)
| | - Fulvia Ferrazzi
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (R.S.); (M.Z.); (V.P.); (F.F.)
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany
| |
Collapse
|
33
|
Park YH, Karantza V, Calhoun SR, Park S, Lee S, Kim JY, Yu JH, Kim SW, Lee JE, Nam SJ, Aktan G, Marsico M. Prevalence, treatment patterns, and prognosis of low estrogen receptor-positive (1% to 10%) breast cancer: a single institution's experience in Korea. Breast Cancer Res Treat 2021; 189:653-663. [PMID: 34487293 DOI: 10.1007/s10549-021-06309-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/22/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE To determine prevalence, clinicopathological characteristics, initial treatments, and outcomes associated with low estrogen receptor (ER)-expressing invasive breast cancer. METHODS This retrospective, non-interventional database study included patients undergoing surgery with curative intent for invasive ductal or lobular breast cancer. Patients were treated between January 2003-December 2012. Demographics, clinicopathological characteristics, initial treatments, and outcomes were abstracted from patient records. Patients were categorized using immunohistochemistry to determine ER, progesterone receptor, and human epidermal growth factor receptor 2 (HER2) levels. ER-positive patients were subclassified as ER-low (1% to 10%) and ER-high (> 10%) according to the Allred Proportion Score. Disease-free survival (DFS) and overall survival (OS) were estimated by the Kaplan-Meier method and compared among groups by log-rank test. RESULTS 5930 patients were included (median follow-up, 80.9 months). Of all patients included, 117 (2.0%) had ER-low tumors: 63 (53.8%) of whom had HER2- tumors and 54 (46.2%) HER2+ tumors. Five-year DFS and OS were highest in the ER-high/HER2- cohort (94.0% and 98.6%, respectively) and lowest in the triple-negative breast cancer (TNBC; 81.3% and 90.1%) and ER-low/HER2- (85.7% and 92.1%) cohorts. Menopausal status, elevated Ki-67, higher nuclear grade, higher tumor stage, presence of lymphovascular invasion, greater regional lymph node involvement, and larger tumor size were all potential prognostic factors for shorter DFS and OS. CONCLUSION Patients with ER-low/HER2- breast cancer had similar clinicopathological characteristics, treatments, and outcomes as patients with TNBC irrespective of disease setting. Further research is needed to understand predictive and prognostic factors associated with ER-low/HER2- disease.
Collapse
Affiliation(s)
- Yeon Hee Park
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-Gu, Seoul, 06351, South Korea.
| | | | | | - Seri Park
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sohee Lee
- Samsung Biomedical Research Institute, Samsung Medical Center, Seoul, South Korea
| | - Ji-Yeon Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-Gu, Seoul, 06351, South Korea
| | - Jong Han Yu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seok Won Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeong Eon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seok Jin Nam
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | | | | |
Collapse
|
34
|
Kareva I, Brown JS. Estrogen as an Essential Resource and the Coexistence of ER+ and ER– Cancer Cells. Front Ecol Evol 2021. [DOI: 10.3389/fevo.2021.673082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Diagnosis of estrogen sensitivity in breast cancer is largely predicated on the ratio of ER+ and ER– cancer cells obtained from biopsies. Estrogen is a growth factor necessary for cell survival and division. It can also be thought of as an essential resource that can act in association with other nutrients, glucose, glutamine, fatty acids, amino acids, etc. All of these nutrients, collectively or individually, may limit the growth of the cancer cells (Liebig’s Law of the Minimum). Here we model estrogen susceptibility in breast cancer as a consumer-resource interaction: ER+ cells require both estrogen and glucose as essential resources, whereas ER– only require the general resource. The model predicts that when estrogen is the limiting factor, other nutrients may go unconsumed and available at higher levels, thus permitting the invasion of ER– cells. Conversely, when ER– cells are less efficient on glucose than ER+ cells, then ER– cells limited by glucose may be susceptible to invasion by ER+ cells, provided that sufficient levels of estrogen are available. ER+ cells will outcompete ER– cells when estrogen is abundant, resulting in low concentrations of interstitial glucose within the tumor. In the absence of estrogen, ER– cells will outcompete ER+ cells, leaving a higher concentration of interstitial glucose. At intermediate delivery rates of estrogen and glucose, ER+ and ER– cells are predicted to coexist. In modeling the dynamics of cells in the same tumor with different resource requirements, we can apply concepts and terms familiar to many ecologists. These include: resource supply points, R∗, ZNGI (zero net growth isoclines), resource depletion, and resource uptake rates. Based on the circumstances favoring ER+ vs. ER– breast cancer, we use the model to explore the consequences of therapeutic regimens that may include hormonal therapies, possible roles of diet in changing cancer cell composition, and potential for evolutionarily informed therapies. More generally, the model invites the viewpoint that cancer’s eco-evolutionary dynamics are a consumer-resource interaction, and that other growth factors such as EGFR or androgens may be best viewed as essential resources within these dynamics.
Collapse
|
35
|
Yu KD, Cai YW, Wu SY, Shui RH, Shao ZM. Estrogen receptor-low breast cancer: Biology chaos and treatment paradox. Cancer Commun (Lond) 2021; 41:968-980. [PMID: 34251757 PMCID: PMC8504145 DOI: 10.1002/cac2.12191] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/23/2021] [Accepted: 06/19/2021] [Indexed: 02/03/2023] Open
Abstract
Hormone receptor testing mainly serves the purpose of guiding treatment choices for breast cancer patients. Patients with estrogen receptor (ER)‐positive breast cancers show significant response to endocrine therapy. However, the methods to define ER status and eligibility for treatment remain controversial. Despite recent guidelines considering staining ≥1% of tumor nuclei by immunohistology as ER‐positive, it has raised concerns on the benefit of endocrine therapy for tumors with ER 1%‐10% expression, termed “ER‐low positive”. This subgroup accounts for 3% to 9% of all patients and is likely to have unique molecular features, and therefore distinct therapeutic response to endocrine therapy compared with ER‐high positive tumors. The latest guidelines did not provide detailed descriptions for those patients, resulting in inconsistent treatment strategies. Consequently, we aimed to resolve this dilemma comprehensively. This review discusses molecular traits and recent ER‐low positive breast cancer innovations, highlighting molecular‐targeted treatment rather than traditional unified endocrine therapy for future basic and clinical research.
Collapse
Affiliation(s)
- Ke-Da Yu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, P. R. China.,Shanghai Medical College, Fudan University, Shanghai, 200032, P. R. China
| | - Yu-Wen Cai
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, P. R. China.,Shanghai Medical College, Fudan University, Shanghai, 200032, P. R. China
| | - Song-Yang Wu
- Shanghai Medical College, Fudan University, Shanghai, 200032, P. R. China
| | - Ruo-Hong Shui
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, 200032, P. R. China
| | - Zhi-Ming Shao
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, P. R. China.,Shanghai Key Laboratory of Breast Cancer, Shanghai, 200032, P. R. China
| |
Collapse
|
36
|
Fei F, Siegal GP, Wei S. Characterization of estrogen receptor-low-positive breast cancer. Breast Cancer Res Treat 2021; 188:225-235. [PMID: 33694051 DOI: 10.1007/s10549-021-06148-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 02/12/2021] [Indexed: 01/09/2023]
Abstract
PURPOSE The biology of breast cancer with a low expression level (1-10%) of estrogen receptor (ER) remains a matter of confusion. The recent American Society of Oncology/College of American Pathologist Guidelines have recommended reporting such tumors as a new "ER-low-positive" category with a recommended comment to emphasize the possible overall benefit of endocrine therapies in these patients. The aim of the study was to analyze the clinicopathologic features and clinical outcomes of ER-low-positive breast cancers. METHODS We characterized the clinicopathologic features and survival outcomes of ER-low-positive breast cancers in our 4179 patients diagnosed from 1998 to 2018. RESULTS The ER-positive, ER-low-positive, and ER-negative cases in our cohort were 2982 (71.4%), 97 (2.3%), and 1100 (26.3%), respectively. ER-low-positive tumors showed similar clinicopathologic characteristics yet significantly superior prognosis when compared to ER-negative tumors, while demonstrated largely overlapping survival outcomes with ER-positive tumors in the entire cohort. In the subcohort of tumors with a PR-positive phenotype, the prognosis of ER-low-positive tumors was intermediate between that of the ER-positive and ER-negative groups. ER-low-positive/PR-positive tumors had a significantly worse prognosis than ER-positive tumors, and a trend toward favorable survival outcomes when compared to ER-negative tumors, although no significant difference was identified for the latter. In contrast, the ER-positive and ER-low-positive groups showed similar survival outcomes in the subset of tumors with a PR-negative status, both being significantly better than ER-negative tumors. CONCLUSIONS PR status as a surrogate marker of functional ER signaling provides critical information in this regard. These findings suggest that while ER-low-positive tumors are themselves heterogeneous, they often respond to endocrine treatment. Analysis of molecular signatures and standardization of therapeutic strategies are important to understand the biology of ER-low-positive tumors and to enable optimal treatment in the pursuit of individualized medicine.
Collapse
Affiliation(s)
- Fei Fei
- Department of Pathology, University of Alabama at Birmingham, NP 3545, 619 19th St. South, Birmingham, AL, 35249-7331, USA
| | - Gene P Siegal
- Department of Pathology, University of Alabama at Birmingham, NP 3545, 619 19th St. South, Birmingham, AL, 35249-7331, USA.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, 35249, USA
| | - Shi Wei
- Department of Pathology, University of Alabama at Birmingham, NP 3545, 619 19th St. South, Birmingham, AL, 35249-7331, USA. .,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, 35249, USA.
| |
Collapse
|
37
|
Prognostic and predictive parameters in breast pathology: a pathologist's primer. Mod Pathol 2021; 34:94-106. [PMID: 33154551 DOI: 10.1038/s41379-020-00704-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/02/2020] [Accepted: 10/02/2020] [Indexed: 12/13/2022]
Abstract
The pathologist's role in the breast cancer treatment team has evolved from rendering a diagnosis of breast cancer, to providing a growing list of prognostic and predictive parameters such that individualized treatment decisions can be made based on likelihood of benefit from additional treatments and potential benefit from specific therapies. In all stages, ER and HER2 status help segregate breast cancers into treatment groups with similar outcomes and treatment response rates, however, traditional pathologic parameters such as favorable histologic subtype, size, lymph node status, and Nottingham grade also have remained clinically relevant in early stage disease decision-making. This is especially true for the most common subtype of breast cancer; ER positive, HER2 negative disease. For this same group of breast cancers, an ever-expanding list of gene-expression panels also can provide prediction and prognostication about potential chemotherapy benefit beyond standard endocrine therapies, with the 21-gene Recurrence Score, currently the only prospectively validated predictive test for this purpose. In the more aggressive ER-negative cancer subtypes, response to neoadjuvant therapy and` the extent of tumor infiltrating lymphocytes (TILs) are more recently recognized powerful prognostic parameters, and clinical guidelines now offer additional treatment options for those high-risk patients with residual cancer after standard neoadjuvant therapy. In stage four disease, predictive tests like germline BRCA status, tumor PIK3CA mutation status (in ER+ metastatic disease) and PDL-1 status (in triple negative metastatic disease) are now used to determine additional new treatment options. The objective of this review is to describe the latest in prognostic and predictive parameters in breast cancer as they are relevant to standard pathology reporting and how they are used in breast cancer clinical treatment decisions.
Collapse
|
38
|
Szymiczek A, Lone A, Akbari MR. Molecular intrinsic versus clinical subtyping in breast cancer: A comprehensive review. Clin Genet 2020; 99:613-637. [PMID: 33340095 DOI: 10.1111/cge.13900] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 12/15/2022]
Abstract
Breast cancer is a heterogeneous disease manifesting diversity at the molecular, histological and clinical level. The development of breast cancer classification was centered on informing clinical decisions. The current approach to the classification of breast cancer, which categorizes this disease into clinical subtypes based on the detection of estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2, and proliferation marker Ki67, is not ideal. This is manifested as a heterogeneity of therapeutic responses and outcomes within the clinical subtypes. The newer classification model, based on gene expression profiling (intrinsic subtyping) informs about transcriptional responses downstream from IHC single markers, revealing deeper appreciation for the disease heterogeneity and capturing tumor biology in a more comprehensive way than an expression of a single protein or gene alone. While accumulating evidences suggest that intrinsic subtypes provide clinically relevant information beyond clinical surrogates, it is imperative to establish whether the current conventional immunohistochemistry-based clinical subtyping approach could be improved by gene expression profiling and if this approach has a potential to translate into clinical practice.
Collapse
Affiliation(s)
- Agata Szymiczek
- Women's College Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Amna Lone
- Women's College Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Mohammad R Akbari
- Women's College Research Institute, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
39
|
Cardoso F, Paluch-Shimon S, Senkus E, Curigliano G, Aapro MS, André F, Barrios CH, Bergh J, Bhattacharyya GS, Biganzoli L, Boyle F, Cardoso MJ, Carey LA, Cortés J, El Saghir NS, Elzayat M, Eniu A, Fallowfield L, Francis PA, Gelmon K, Gligorov J, Haidinger R, Harbeck N, Hu X, Kaufman B, Kaur R, Kiely BE, Kim SB, Lin NU, Mertz SA, Neciosup S, Offersen BV, Ohno S, Pagani O, Prat A, Penault-Llorca F, Rugo HS, Sledge GW, Thomssen C, Vorobiof DA, Wiseman T, Xu B, Norton L, Costa A, Winer EP. 5th ESO-ESMO international consensus guidelines for advanced breast cancer (ABC 5). Ann Oncol 2020; 31:1623-1649. [PMID: 32979513 PMCID: PMC7510449 DOI: 10.1016/j.annonc.2020.09.010] [Citation(s) in RCA: 703] [Impact Index Per Article: 175.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 01/09/2023] Open
Affiliation(s)
- F Cardoso
- Breast Unit, Champalimaud Clinical Centre/Champalimaud Foundation, Lisbon, Portugal.
| | - S Paluch-Shimon
- Sharett Division of Oncology, Hadassah University Hospital, Jerusalem, Israel
| | - E Senkus
- Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland
| | - G Curigliano
- Department of Oncology and Hemato-Oncology, European Institute of Oncology, IRCCS, Division of Early Drug Development, University of Milan, Milan, Italy
| | - M S Aapro
- Breast Center, Clinique de Genolier, Genolier, Switzerland
| | - F André
- Department of Medical Oncology, Institut Gustave Roussy, Villejuif, France
| | - C H Barrios
- Latin American Cooperative Oncology Group (LACOG), Grupo Oncoclínicas, Porto Alegre, Brazil
| | - J Bergh
- Department of Oncology-Pathology, Karolinska Institute & University Hospital, Stockholm, Sweden
| | - G S Bhattacharyya
- Department of Medical Oncology, Salt Lake City Medical Centre, Kolkata, India
| | - L Biganzoli
- Department of Medical Oncology, Nuovo Ospedale di Prato - Istituto Toscano Tumori, Prato, Italy
| | - F Boyle
- The Pam McLean Centre, Royal North Shore Hospital, St Leonards, Australia
| | - M-J Cardoso
- Breast Unit, Champalimaud Clinical Centre/Champalimaud Foundation, Lisbon, Portugal; Nova Medical School, Lisbon, Portugal
| | - L A Carey
- Department of Hematology and Oncology, UNC Lineberger Comprehensive Cancer Center, Chapel Hill, USA
| | - J Cortés
- IOB Institute of Oncology, Quiron Group, Madrid & Barcelona, Spain; Department of Oncology, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - N S El Saghir
- Division of Hematology Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - M Elzayat
- Europa Donna, The European Breast Cancer Coalition, Milan, Italy
| | - A Eniu
- Interdisciplinary Oncology Service (SIC), Riviera-Chablais Hospital, Rennaz, Switzerland
| | - L Fallowfield
- SHORE-C, Brighton & Sussex Medical School, University of Sussex, Brighton, UK
| | - P A Francis
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - K Gelmon
- Medical Oncology Department, BC Cancer Agency, Vancouver, Canada
| | - J Gligorov
- Breast Cancer Expert Center, University Cancer Institute APHP, Sorbonne University, Paris, France
| | - R Haidinger
- Brustkrebs Deutschland e.V., Munich, Germany
| | - N Harbeck
- Breast Centre, Department of Obstetrics and Gynaecology, University of Munich (LMU), Munich, Germany
| | - X Hu
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - B Kaufman
- Department of Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - R Kaur
- Breast Cancer Welfare Association Malaysia, Petaling Jaya, Malaysia
| | - B E Kiely
- NHMRC Clinical Trials Centre, Sydney Medical School, Sydney, Australia
| | - S-B Kim
- Department of Oncology, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
| | - N U Lin
- Susan Smith Center for Women's Cancers - Breast Oncology Center, Dana-Farber Cancer Institute, Boston, USA
| | - S A Mertz
- Metastatic Breast Cancer Network, Inverness, USA
| | - S Neciosup
- Department of Medical Oncology, National Institute of Neoplastic Diseases, Lima, Peru
| | - B V Offersen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - S Ohno
- Breast Oncology Centre, Cancer Institute Hospital, Tokyo, Japan
| | - O Pagani
- Medical School, Geneva University Hospital, Geneva, Switzerland
| | - A Prat
- Department of Medical Oncology, Hospital Clinic of Barcelona, Barcelona, Spain; Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, Barcelona; Department of Medicine, University of Barcelona, Barcelona
| | - F Penault-Llorca
- Department of Biopathology, Centre Jean Perrin, Clermont-Ferrand, France; University Clermont Auvergne/INSERM U1240, Clermont-Ferrand, France
| | - H S Rugo
- Breast Oncology Clinical Trials Education, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, USA
| | - G W Sledge
- Division of Oncology, Stanford School of Medicine, Stanford, USA
| | - C Thomssen
- Department of Gynaecology, Martin Luther University Halle-Wittenburg, Halle, Germany
| | - D A Vorobiof
- Oncology Research Unit, Belong.Life, Tel Aviv, Israel
| | - T Wiseman
- Department of Applied Health Research in Cancer Care, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - B Xu
- Department of Medical Oncology, Cancer Hospital Chinese Academy of Medical Sciences, Beijing, China
| | - L Norton
- Breast Cancer Medicine Service, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - A Costa
- European School of Oncology, Milan, Italy; European School of Oncology, Bellinzona, Switzerland
| | - E P Winer
- Susan Smith Center for Women's Cancers - Breast Oncology Center, Dana-Farber Cancer Institute, Boston, USA
| |
Collapse
|
40
|
Tumor-infiltrating lymphocytes are associated with poor prognosis in invasive lobular breast carcinoma. Mod Pathol 2020; 33:2198-2207. [PMID: 32404955 DOI: 10.1038/s41379-020-0561-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 12/14/2022]
Abstract
The prognostic impact of tumor-infiltrating lymphocytes (TILs) within invasive lobular carcinoma (ILC) remains to be better characterized. In estrogen receptor (ER)-negative invasive ductal carcinomas of no special type (IDC-NST), TILs are associated with good prognosis. The aim of this study was to examine TILs in ILC, with particular focus on prognostic and clinicopathologic features. A cohort comprising 459 consecutive ILCs diagnosed in a single institution from 2005 to 2008 met the eligibility criteria for this study. The percentage of tumor area occupied by TILs was quantified by two breast pathologists and categorized into three groups: no TILs, ≤5%, >5%. Clinicopathologic features were tested by Fisher's exact tests or Chi2 tests. Overall survival (OS) and invasive disease-free survival (iDFS) were estimated by Kaplan-Meier and Cox proportional hazard statistics. There were 239 TIL-negative cases, 185 cases with ≤5% TILs, and 35 cases with >5% TILs. TILs were associated with younger age, larger tumors, lymph node involvement, poor Nottingham prognostic index, HER2 amplification, multinucleation, and prominent nucleoli (p < 0.05). Poor OS was significantly associated with increasing TILs in the univariate Cox proportional hazards model (p < 0.001) and Kaplan-Meier estimator (p < 0.05, log-rank test). Similar results were observed for iDFS (p = 0.004 for Cox univariate and p = 0.005 for log-rank test). Notably, TILs can identify a subset of ILC patients with poor OS independently of molecular subtype and lymph node metastases (multivariate Cox, p < 0.001, OS hazard ratio (HR) = 4.38 and HR = 6.15, for ≤5% and >5% TILs, respectively, vs. absence of TILs). Prominent nucleoli was the only nuclear feature associated with poor OS (p = 0.05) and iDFS (p = 0.05) in univariate Cox survival analysis. TILs represent a promising new morphologic biomarker associated with poor outcome of ILC, in contrast with that observed in ER-negative IDC-NST.
Collapse
|
41
|
Validation of Prognostic Stage and Anatomic Stage in the American Joint Committee on Cancer 8th Edition for Inflammatory Breast Cancer. Cancers (Basel) 2020; 12:cancers12113105. [PMID: 33114311 PMCID: PMC7690918 DOI: 10.3390/cancers12113105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 10/15/2020] [Accepted: 10/18/2020] [Indexed: 11/16/2022] Open
Abstract
The AJCC updated its breast cancer staging system to incorporate biological factors in the "prognostic stage". We undertook this study to validate the prognostic and anatomic stages for inflammatory breast cancer (IBC). We established two cohorts of IBC diagnosed without distant metastasis: (1) patients treated at The University of Texas MD Anderson Cancer Center between 1991 and 2017 (MDA cohort) and (2) patients registered in the national Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015 (SEER cohort). For prognostic staging, estrogen receptor (ER)+/progesterone receptor (PR)+/ human epidermal growth factor receptor-2 (HER2)+/grade 1-2 was staged as IIIA; ER+/PR-/HER2-/grade 3, ER-/PR+/HER2-/grade 3, and triple-negative cancers as IIIC; and all others as IIIB. Endpoints were breast cancer-specific survival (BCSS), overall survival (OS), and disease-free survival (DFS). We studied 885 patients in the MDA cohort and 338 in the SEER cohort. In the MDA cohort, the prognostic stage showed significant predictive power for BCSS, OS, and DFS (all p < 0.0001), although the anatomic stage did not. In both cohorts, the Harrell concordance index (C index) was significantly higher in the prognostic stage than the anatomic stage for all endpoints. In conclusion, the prognostic stage provided more accurate prognostication for IBC than the anatomic stage. Our results show that the prognostic staging is applicable in IBC.
Collapse
|
42
|
Holm J, Yu NYL, Johansson A, Ploner A, Hall P, Lindström LS, Czene K. Concordance of Immunohistochemistry-Based and Gene Expression-Based Subtyping in Breast Cancer. JNCI Cancer Spectr 2020; 5:pkaa087. [PMID: 33442660 PMCID: PMC7791620 DOI: 10.1093/jncics/pkaa087] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/05/2020] [Accepted: 09/08/2020] [Indexed: 12/04/2022] Open
Abstract
Background Use of immunohistochemistry-based surrogates of molecular breast cancer subtypes is common in research and clinical practice, but information on their comparative validity and prognostic capacity is scarce. Methods Data from 2 PAM50-subtyped Swedish breast cancer cohorts were used: Stockholm tamoxifen trial–3 with 561 patients diagnosed 1976-1990 and Clinseq with 237 patients diagnosed 2005-2012. We evaluated 3 surrogate classifications; the immunohistochemistry-3 surrogate classifier based on estrogen receptor, progesterone receptor, and HER2 and the St. Gallen and Prolif surrogate classifiers also including Ki-67. Accuracy, kappa, sensitivity, and specificity were computed as compared with PAM50. Alluvial diagrams of misclassification patterns were plotted. Distant recurrence-free survival was assessed using Kaplan-Meier plots, and tamoxifen treatment benefit for luminal subtypes was modeled using flexible parametric survival models. Results The concordance with PAM50 ranged from poor to moderate (kappa = 0.36-0.57, accuracy = 0.54-0.75), with best performance for the Prolif surrogate classification in both cohorts. Good concordance was only achieved when luminal subgroups were collapsed (kappa = 0.71-0.69, accuracy = 0.90-0.91). The St. Gallen surrogate classification misclassified luminal A into luminal B; the reverse pattern was seen with the others. In distant recurrence-free survival, surrogates were more similar to each other than PAM50. The difference in tamoxifen treatment benefit between luminal A and B for PAM50 was not replicated with any surrogate classifier. Conclusions All surrogate classifiers had limited ability to distinguish between PAM50 luminal A and B, but patterns of misclassifications differed. PAM50 subtyping appeared to yield larger separation of survival between luminal subtypes than any of the surrogate classifications.
Collapse
Affiliation(s)
- Johanna Holm
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Nancy Yiu-Lin Yu
- Department of Biosciences and Nutrition, Karolinska Institutet, Stockholm, Sweden
| | - Annelie Johansson
- Department of Biosciences and Nutrition, Karolinska Institutet, Stockholm, Sweden.,Department of Oncology and Pathology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Alexander Ploner
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Per Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Oncology, Södersjukhuset, Stockholm, Sweden
| | | | - Kamila Czene
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
43
|
The significance of highlighting the oestrogen receptor low category in breast cancer. Br J Cancer 2020; 123:1223-1227. [PMID: 32713939 PMCID: PMC7555863 DOI: 10.1038/s41416-020-1009-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/30/2020] [Accepted: 07/08/2020] [Indexed: 02/03/2023] Open
Abstract
The latest ASCO/CAP guideline has recommended to report oestrogen receptor (ER) low cases (ERlo; 1-10%) as "ER low positive category", prompting us to compare the clinicopathologic features, biomarkers, survival and treatment of the ERlo cases with other subgroups (ER negative (ERneg) and ER high (ERhi)). ERlo cases revealed more similar clinicopathologic and biomarker profiles (including younger age, larger tumour, high proliferation, HER2 and basal markers expression) to ERneg than ERhi cancers. The ERlo cases receiving hormonal therapy showed a similarly poor outcome as ERneg cancers. However, majority of ERlo cases were downstaged to stage I in the 8th AJCC pathological prognostic staging, highlighting a risk of potential under treatment. Overall, our data highlighted the differences of ERlo from other ERpos cases and their management should be considered separately.
Collapse
|
44
|
Benefield HC, Allott EH, Reeder-Hayes KE, Perou CM, Carey LA, Geradts J, Sun X, Calhoun BC, Troester MA. Borderline Estrogen Receptor-Positive Breast Cancers in Black and White Women. J Natl Cancer Inst 2020; 112:728-736. [PMID: 31742342 PMCID: PMC7357313 DOI: 10.1093/jnci/djz206] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 09/27/2019] [Accepted: 10/15/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Some breast tumors expressing greater than 1% and less than 10% estrogen receptor (ER) positivity (ER-borderline) are clinically aggressive; others exhibit luminal biology. Prior ER-borderline studies included few black participants. METHODS Using the Carolina Breast Cancer Study (phase I: 1993-1996; 2: 1996-2001; 3: 2008-2013), a population-based study that oversampled black women, we compared ER-borderline (n = 217) to ER-positive (n = 1885) and ER-negative (n = 757) tumors. PAM50 subtype and risk of recurrence score (ROR-PT, incorporates subtype, proliferation, tumor size) were measured. Relative frequency differences (RFD) were estimated using multivariable linear regression. Disease-free interval (DFI) was evaluated by ER category and endocrine therapy receipt, overall and by race, using Kaplan Meier and Cox models. Statistical tests were two-sided. RESULTS ER-borderlines were more frequently basal-like (RFD = +37.7%, 95% confidence interval [CI] = 27.1% to 48.4%) and high ROR-PT (RFD = +52.4%, 95% CI = 36.8% to 68.0%) relative to ER-positives. Having a high ROR-PT ER-borderline tumor was statistically significantly associated with black race (RFD = +26.2%, 95% CI = 9.0% to 43.3%). Compared to ER-positives, DFI of ER-borderlines treated with endocrine therapy was poorer but not statistically significantly different (hazard ratio [HR] = 2.03, 95% CI = 0.89% to 4.65%), whereas DFI was statistically significantly worse for ER-borderlines without endocrine therapy (HR = 3.33, 95% CI = 1.84% to 6.02%). However, black women with ER-borderline had worse DFI compared to ER-positives, even when treated with endocrine therapy (HR = 2.77, 95% CI = 1.09% to 7.04%). CONCLUSIONS ER-borderline tumors were genomically heterogeneous, with survival outcomes that differed by endocrine therapy receipt and race. Black race predicted high-risk ER-borderlines and may be associated with poorer endocrine therapy response.
Collapse
Affiliation(s)
| | - Emma H Allott
- University of North Carolina at Chapel Hill, Chapel Hill, NC; Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, Northern Ireland, UK
| | | | | | | | - Joseph Geradts
- City of Hope National Medical Center, Department of Population Sciences, Duarte
| | - Xuezheng Sun
- Department of Epidemiology, Gillings School of Global Public Health
| | - Benjamin C Calhoun
- Department of Genetics
- Department of Medical Oncology
- Department of Pathology and Laboratory Medicine
| | | |
Collapse
|
45
|
Zilenaite D, Rasmusson A, Augulis R, Besusparis J, Laurinaviciene A, Plancoulaine B, Ostapenko V, Laurinavicius A. Independent Prognostic Value of Intratumoral Heterogeneity and Immune Response Features by Automated Digital Immunohistochemistry Analysis in Early Hormone Receptor-Positive Breast Carcinoma. Front Oncol 2020; 10:950. [PMID: 32612954 PMCID: PMC7308549 DOI: 10.3389/fonc.2020.00950] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022] Open
Abstract
Immunohistochemistry (IHC) for ER, PR, HER2, and Ki67 is used to predict outcome and therapy response in breast cancer patients. The current IHC assessment, visual or digital, is based mostly on global biomarker expression levels in the tissue sample. In our study, we explored the prognostic value of digital image analysis of conventional breast cancer IHC biomarkers supplemented with their intratumoral heterogeneity and tissue immune response indicators. Surgically excised tumor samples from 101 female patients with hormone receptor-positive breast cancer (HRBC) were stained for ER, PR, HER2, Ki67, SATB1, CD8, and scanned at 20x. Digital image analysis was performed using the HALO™ platform. Subsequently, hexagonal tiling was used to compute intratumoral heterogeneity indicators for ER, PR and Ki67 expression. Multiple Cox regression analysis revealed three independent predictors of the patient's overall survival: Haralick's texture entropy of PR (HR = 0.19, p = 0.0005), Ki67 Ashman's D bimodality (HR = 3.0, p = 0.01), and CD8+SATB1+ cell density in tumor tissue (HR = 0.32, p = 0.02). Remarkably, the PR and Ki67 intratumoral heterogeneity indicators were prognostically more informative than the rates of their expression. In particular, a distinct non-linear relationship between the rate of PR expression and its intratumoral heterogeneity was observed and revealed a non-linear prognostic effect of PR expression. The independent prognostic significance of CD8+SATB1+ cells infiltrating the tumor could indicate their role in anti-tumor immunity. In conclusion, we suggest that prognostic modeling, based entirely on the computational image-based IHC biomarkers, is possible in HRBC patients. The intratumoral heterogeneity and immune response indicators outperformed both conventional breast cancer IHC and clinicopathological variables while markedly increasing the power of the model.
Collapse
Affiliation(s)
- Dovile Zilenaite
- Department of Pathology, Forensic Medicine and Pharmacology, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania.,National Centre of Pathology, Affiliate of Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania
| | - Allan Rasmusson
- Department of Pathology, Forensic Medicine and Pharmacology, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania.,National Centre of Pathology, Affiliate of Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania
| | - Renaldas Augulis
- Department of Pathology, Forensic Medicine and Pharmacology, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania.,National Centre of Pathology, Affiliate of Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania
| | - Justinas Besusparis
- Department of Pathology, Forensic Medicine and Pharmacology, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania.,National Centre of Pathology, Affiliate of Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania
| | - Aida Laurinaviciene
- Department of Pathology, Forensic Medicine and Pharmacology, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania.,National Centre of Pathology, Affiliate of Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania
| | - Benoit Plancoulaine
- Department of Pathology, Forensic Medicine and Pharmacology, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania.,ANTICIPE, Inserm (UMR 1086), Cancer Center F. Baclesse, Normandy University, Caen, France
| | - Valerijus Ostapenko
- Department of Breast Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania
| | - Arvydas Laurinavicius
- Department of Pathology, Forensic Medicine and Pharmacology, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania.,National Centre of Pathology, Affiliate of Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania
| |
Collapse
|
46
|
Allison KH, Hammond MEH, Dowsett M, McKernin SE, Carey LA, Fitzgibbons PL, Hayes DF, Lakhani SR, Chavez-MacGregor M, Perlmutter J, Perou CM, Regan MM, Rimm DL, Symmans WF, Torlakovic EE, Varella L, Viale G, Weisberg TF, McShane LM, Wolff AC. Estrogen and Progesterone Receptor Testing in Breast Cancer: American Society of Clinical Oncology/College of American Pathologists Guideline Update. Arch Pathol Lab Med 2020; 144:545-563. [PMID: 31928354 DOI: 10.5858/arpa.2019-0904-sa] [Citation(s) in RCA: 177] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE.— To update key recommendations of the American Society of Clinical Oncology/College of American Pathologists estrogen receptor (ER) and progesterone receptor (PgR) testing in breast cancer guideline. METHODS.— A multidisciplinary international Expert Panel was convened to update the clinical practice guideline recommendations informed by a systematic review of the medical literature. RECOMMENDATIONS.— The Expert Panel continues to recommend ER testing of invasive breast cancers by validated immunohistochemistry as the standard for predicting which patients may benefit from endocrine therapy, and no other assays are recommended for this purpose. Breast cancer samples with 1% to 100% of tumor nuclei positive should be interpreted as ER positive. However, the Expert Panel acknowledges that there are limited data on endocrine therapy benefit for cancers with 1% to 10% of cells staining ER positive. Samples with these results should be reported using a new reporting category, ER Low Positive, with a recommended comment. A sample is considered ER negative if < 1% or 0% of tumor cell nuclei are immunoreactive. Additional strategies recommended to promote optimal performance, interpretation, and reporting of cases with an initial low to no ER staining result include establishing a laboratory-specific standard operating procedure describing additional steps used by the laboratory to confirm/adjudicate results. The status of controls should be reported for cases with 0% to 10% staining. Similar principles apply to PgR testing, which is used primarily for prognostic purposes in the setting of an ER-positive cancer. Testing of ductal carcinoma in situ (DCIS) for ER is recommended to determine potential benefit of endocrine therapies to reduce risk of future breast cancer, while testing DCIS for PgR is considered optional. Additional information can be found at www.asco.org/breast-cancer-guidelines .
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Sunil R Lakhani
- University of Queensland, Brisbane, Queensland, Australia
- Pathology Queensland, Brisbane, Queensland, Australia
| | | | | | | | - Meredith M Regan
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | | | - Emina E Torlakovic
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Giuseppe Viale
- IEO, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- University of Milan, Milan, Italy
| | | | | | | |
Collapse
|
47
|
Allison KH, Hammond MEH, Dowsett M, McKernin SE, Carey LA, Fitzgibbons PL, Hayes DF, Lakhani SR, Chavez-MacGregor M, Perlmutter J, Perou CM, Regan MM, Rimm DL, Symmans WF, Torlakovic EE, Varella L, Viale G, Weisberg TF, McShane LM, Wolff AC. Estrogen and Progesterone Receptor Testing in Breast Cancer: ASCO/CAP Guideline Update. J Clin Oncol 2020; 38:1346-1366. [PMID: 31928404 DOI: 10.1200/jco.19.02309] [Citation(s) in RCA: 640] [Impact Index Per Article: 160.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2019] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To update key recommendations of the American Society of Clinical Oncology/College of American Pathologists estrogen (ER) and progesterone receptor (PgR) testing in breast cancer guideline. METHODS A multidisciplinary international Expert Panel was convened to update the clinical practice guideline recommendations informed by a systematic review of the medical literature. RECOMMENDATIONS The Expert Panel continues to recommend ER testing of invasive breast cancers by validated immunohistochemistry as the standard for predicting which patients may benefit from endocrine therapy, and no other assays are recommended for this purpose. Breast cancer samples with 1% to 100% of tumor nuclei positive should be interpreted as ER positive. However, the Expert Panel acknowledges that there are limited data on endocrine therapy benefit for cancers with 1% to 10% of cells staining ER positive. Samples with these results should be reported using a new reporting category, ER Low Positive, with a recommended comment. A sample is considered ER negative if < 1% or 0% of tumor cell nuclei are immunoreactive. Additional strategies recommended to promote optimal performance, interpretation, and reporting of cases with an initial low to no ER staining result include establishing a laboratory-specific standard operating procedure describing additional steps used by the laboratory to confirm/adjudicate results. The status of controls should be reported for cases with 0% to 10% staining. Similar principles apply to PgR testing, which is used primarily for prognostic purposes in the setting of an ER-positive cancer. Testing of ductal carcinoma in situ (DCIS) for ER is recommended to determine potential benefit of endocrine therapies to reduce risk of future breast cancer, while testing DCIS for PgR is considered optional. Additional information can be found at www.asco.org/breast-cancer-guidelines.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Sunil R Lakhani
- University of Queensland, Brisbane, Queensland, Australia
- Pathology Queensland, Brisbane, Queensland, Australia
| | | | | | | | - Meredith M Regan
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | | | - Emina E Torlakovic
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Giuseppe Viale
- IEO, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- University of Milan, Milan, Italy
| | | | | | | |
Collapse
|
48
|
Tečić Vuger A, Šeparović R, Vazdar L, Pavlović M, Lepetić P, Šitić S, Bajić Ž, Šarčević B, Vrbanec D. CHARACTERISTICS AND PROGNOSIS OF TRIPLE-NEGATIVE BREAST CANCER PATIENTS: A CROATIAN SINGLE INstitution RETROSPECTIVE COHORT STUDY. Acta Clin Croat 2020; 59:97-108. [PMID: 32724280 PMCID: PMC7382886 DOI: 10.20471/acc.2020.59.01.12] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Triple-negative breast cancer (TNBC) occurs in around one-sixth of all breast cancer (BC) patients, with the most aggressive behavior and worst prognosis of all BC subtypes. It is a heterogeneous disease, with specific molecular characteristics and natural dynamics of early recurrence and fast progression. Due to the lack of biomarkers or any valid treatment targets, it can only be treated with classic cytotoxic chemotherapy. We analyzed a cohort of 152 patients, median age 58 years, diagnosed with and treated for early stage TNBC at the University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia, during the 2009-2012 period. Patients were treated with primary surgical approach, adjuvant chemotherapy and adjuvant irradiation. We observed a relatively large proportion of locally advanced TNBC at diagnosis, with large tumor size and nodal involvement, with high grade and high proliferation index Ki67. Patient age, tumor size and lymph node involvement, as expected, were significant and clinically most important prognostic factors for 5-year disease-free survival (67%; 95% CI 60%-75%) and overall absolute survival rate (74%; 95% CI 66%-81%).
Collapse
Affiliation(s)
| | - Robert Šeparović
- 1Department of Medical Oncology, Division of Radiotherapy and Medical Oncology, University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Department of Oncologic Cytology and Pathology, University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 3Dr. Mirko Grmek Scientific Unit, Sveti Ivan Psychiatric Hospital, Zagreb, Croatia; 4School of Medicine, University of Zagreb, Zagreb, Croatia; 5School of Medicine, Juraj Dobrila University, Pula, Croatia
| | - Ljubica Vazdar
- 1Department of Medical Oncology, Division of Radiotherapy and Medical Oncology, University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Department of Oncologic Cytology and Pathology, University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 3Dr. Mirko Grmek Scientific Unit, Sveti Ivan Psychiatric Hospital, Zagreb, Croatia; 4School of Medicine, University of Zagreb, Zagreb, Croatia; 5School of Medicine, Juraj Dobrila University, Pula, Croatia
| | - Mirjana Pavlović
- 1Department of Medical Oncology, Division of Radiotherapy and Medical Oncology, University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Department of Oncologic Cytology and Pathology, University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 3Dr. Mirko Grmek Scientific Unit, Sveti Ivan Psychiatric Hospital, Zagreb, Croatia; 4School of Medicine, University of Zagreb, Zagreb, Croatia; 5School of Medicine, Juraj Dobrila University, Pula, Croatia
| | - Petra Lepetić
- 1Department of Medical Oncology, Division of Radiotherapy and Medical Oncology, University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Department of Oncologic Cytology and Pathology, University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 3Dr. Mirko Grmek Scientific Unit, Sveti Ivan Psychiatric Hospital, Zagreb, Croatia; 4School of Medicine, University of Zagreb, Zagreb, Croatia; 5School of Medicine, Juraj Dobrila University, Pula, Croatia
| | - Sanda Šitić
- 1Department of Medical Oncology, Division of Radiotherapy and Medical Oncology, University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Department of Oncologic Cytology and Pathology, University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 3Dr. Mirko Grmek Scientific Unit, Sveti Ivan Psychiatric Hospital, Zagreb, Croatia; 4School of Medicine, University of Zagreb, Zagreb, Croatia; 5School of Medicine, Juraj Dobrila University, Pula, Croatia
| | - Žarko Bajić
- 1Department of Medical Oncology, Division of Radiotherapy and Medical Oncology, University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Department of Oncologic Cytology and Pathology, University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 3Dr. Mirko Grmek Scientific Unit, Sveti Ivan Psychiatric Hospital, Zagreb, Croatia; 4School of Medicine, University of Zagreb, Zagreb, Croatia; 5School of Medicine, Juraj Dobrila University, Pula, Croatia
| | - Božena Šarčević
- 1Department of Medical Oncology, Division of Radiotherapy and Medical Oncology, University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Department of Oncologic Cytology and Pathology, University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 3Dr. Mirko Grmek Scientific Unit, Sveti Ivan Psychiatric Hospital, Zagreb, Croatia; 4School of Medicine, University of Zagreb, Zagreb, Croatia; 5School of Medicine, Juraj Dobrila University, Pula, Croatia
| | - Damir Vrbanec
- 1Department of Medical Oncology, Division of Radiotherapy and Medical Oncology, University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Department of Oncologic Cytology and Pathology, University Hospital for Tumors, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 3Dr. Mirko Grmek Scientific Unit, Sveti Ivan Psychiatric Hospital, Zagreb, Croatia; 4School of Medicine, University of Zagreb, Zagreb, Croatia; 5School of Medicine, Juraj Dobrila University, Pula, Croatia
| |
Collapse
|
49
|
Tecalco-Cruz AC, Ramírez-Jarquín JO, Cruz-Ramos E. Estrogen Receptor Alpha and its Ubiquitination in Breast Cancer Cells. Curr Drug Targets 2019; 20:690-704. [DOI: 10.2174/1389450119666181015114041] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 10/09/2018] [Accepted: 10/09/2018] [Indexed: 12/23/2022]
Abstract
More than 70% of all breast cancer cases are estrogen receptor alpha-positive (ERα). ERα is a member of the nuclear receptor family, and its activity is implicated in the gene transcription linked to the proliferation of breast cancer cells, as well as in extranuclear signaling pathways related to the development of resistance to endocrine therapy. Protein-protein interactions and posttranslational modifications of ERα underlie critical mechanisms that modulate its activity. In this review, the relationship between ERα and ubiquitin protein (Ub), was investigated in the context of breast cancer cells. Interestingly, Ub can bind covalently or non-covalently to ERα resulting in either a proteolytic or non-proteolytic fate for this receptor. Thereby, Ub-dependent molecular pathways that modulate ERα signaling may play a central role in breast cancer progression, and consequently, present critical targets for treatment of this disease.
Collapse
Affiliation(s)
- Angeles C. Tecalco-Cruz
- Instituto de Investigaciones Biomedicas. Universidad Nacional Autonoma de Mexico. Mexico City, 04510, Mexico
| | - Josué O. Ramírez-Jarquín
- Instituto de Fisiologia Celular. Universidad Nacional Autonoma de Mexico. Mexico City, 04510, Mexico
| | - Eduardo Cruz-Ramos
- Instituto de Investigaciones Biomedicas. Universidad Nacional Autonoma de Mexico. Mexico City, 04510, Mexico
| |
Collapse
|
50
|
Inflammatory and other breast cancer incidence rate trends by estrogen receptor status in the Surveillance, Epidemiology, and End Results database (2001-2015). Breast Cancer Res Treat 2019; 175:755-764. [PMID: 30915662 DOI: 10.1007/s10549-019-05193-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 03/05/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Inflammatory breast cancer (IBC) rates increased in the United States before the turn of the twenty-first century. We examine trends by estrogen receptor (ER) status since then. METHODS Using data from the Surveillance, Epidemiology, and End Results (SEER) program for years 2001-2015, we calculated age-adjusted incidence rates for IBC (defined by AJCC TNM category T4d, extent of disease codes, and morphology code 8530) by ER status, which was imputed if unknown, among women aged 25-84 years. For comparison, we included other locally advanced breast cancer and other breast cancers partitioned into localized and regional/distant/unstaged. We fit joinpoint log-linear models to annual rates to calculate annual percentage change (APC) and average annual percentage change (AAPC). RESULTS The rate of increase in ER+ IBC rates among women aged 25-44 (AAPC = 0.5) was similar to other advanced tumor types, but declines among women aged 45-84 (AAPC = - 2.2) were more rapid. Declines in ER- IBC rates for women aged 25-84 (AAPC = - 3.7) were more rapid than for other tumor types. CONCLUSIONS Our results show a reversal of the rising rates of IBC overall reported at the end of the twentieth century. Direction of trends for IBC is consistent with other breast cancer types, except for ER+ localized breast cancer in older women. Decreasing parity and rising prevalence of older age at first birth may contribute to declining rates of ER- IBC. Otherwise, patterns of changing risk factors are inconsistent with the trends we observed. Further studies of IBC are necessary to identify additional risk factors and possible preventive strategies.
Collapse
|