Current Practical Applications of Diagnostic Immunohistochemistry in Breast Pathology

Tumor microenvironment and immune system preservation in early-stage breast cancer: routes for early recurrence after mastectomy and treatment for lobular and ductal forms of disease

BACKGROUND

Intra-ductal cancer (IDC) is the most common type of breast cancer, with intra-lobular cancer (ILC) coming in second. Surgery is the primary treatment for early stage breast cancer. There are now irrefutable data demonstrating that the immune context of breast tumors can influence growth and metastasis. Adjuvant chemotherapy may be administered in patients who are at a high risk of recurrence. Our goal was to identify the processes underlying both types of early local recurrences.

METHODS

This was a case-control observational study. Within 2 years of receiving adjuvant taxan and anthracycline-based chemotherapy, as well as modified radical mastectomy (MRM), early stage IDC and ILC recurred. Vimentin, α-smooth muscle actin (SMA), platelet-derived growth factor (PDGF), matrix metalloproteinase (MMP1), and clustered differentiation (CD95) were investigated.

RESULTS

Of the samples in the ductal type group, 25 showed local recurrence, and 25 did not. Six individuals in the lobular-type group did not experience recurrence, whereas seven did. Vimentin (p = 0.000 and 0.021), PDGF (p = 0.000 and 0.002), and CD95 (p = 0.000 and 0.045) expressions were significantly different in ductal and lobular carcinoma types, respectively. Measurement of ductal type was the sole significant difference found in MMP1 (p = 0.000) and α-SMA (p = 0.000). α-SMA and CD95 were two variables that helped the recurrence mechanism in the ductal type according to the pathway analysis. In contrast, the CD95 route is a recurrent mechanism for the lobular form.

CONCLUSIONS

While the immune system plays a larger role in ILC, the tumor microenvironment and immune system both influence the recurrence of IDC. According to this study, improving the immune system may be a viable cancer treatment option.

Updates in the Use of Immunohistochemical Stains in Breast and Gynecologic Pathology

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.

Krukenberg tumour as the initial manifestation of lung adenocarcinoma

Krukenberg tumours are unusual metastatic tumours of the ovary with primary tumours from the stomach, breast and gastrointestinal malignancies. Krukenberg tumour from pulmonary malignancy represents an extremely rare situation. This is an elaboration of a case of young women with Krukenberg tumour rising from lung adenocarcinoma. A 38‐year‐old woman presented with progressive abdominal distention for the past 2‐years. Computed tomography (CT) of thorax, abdomen and pelvis revealed a huge ovarian mass with left lung nodules and left‐sided pleural effusion. A detailed immunohistochemical staining on pleural fluid cytology confirmed the diagnosis of metastatic adenocarcinoma of lung origin. She underwent doublet platinum chemotherapy as molecular testing for oncogenic mutation was negative. The patient responded well to chemotherapy with a significant reduction in ovarian tumour size. Early identification of the primary source of Krukenberg tumour is paramount to avoid invasive diagnostic surgical intervention for ovarian metastasis.

Ductal Carcinoma in Situ: Molecular Changes Accompanying Disease Progression

Ductal carcinoma in situ (DCIS) is a non-obligate precursor of invasive ductal carcinoma (IDC), whereby if left untreated, approximately 12% of patients develop invasive disease. The current standard of care is surgical removal of the lesion, to prevent potential progression, and radiotherapy to reduce risk of recurrence. There is substantial overtreatment of DCIS patients, considering not all DCIS lesions progress to invasive disease. Hence, there is a critical imperative to better predict which DCIS lesions are destined for poor outcome and which are not, allowing for tailored treatment. Active surveillance is currently being trialed as an alternative management practice, but this approach relies on accurately identifying cases that are at low risk of progression to invasive disease. Two DCIS-specific genomic profiling assays that attempt to distinguish low and high-risk patients have emerged, but imperfections in risk stratification coupled with a high price tag warrant the continued search for more robust and accessible prognostic biomarkers. This search has largely turned researchers toward the tumor microenvironment. Recent evidence suggests that a spectrum of cell types within the DCIS microenvironment are genetically and phenotypically altered compared to normal tissue and play critical roles in disease progression. Uncovering the molecular mechanisms contributing to DCIS progression has provided optimism for the search for well-validated prognostic biomarkers that can accurately predict the risk for a patient developing IDC. The discovery of such markers would modernize DCIS management and allow tailored treatment plans. This review will summarize the current literature regarding DCIS diagnosis, treatment, and pathology.

The Utility of Myoepithelial Cell Layer Identification in Adnexal Carcinomas

ABSTRACT

The distinction of metastatic carcinomas to the skin (MCS) from cutaneous adnexal carcinomas can pose a significant diagnostic challenge. The differentiation between (MCS) from a primary cutaneous adnexal tumor is one of the most difficult tasks in the field of dermatopathology, and immunohistochemistry has only been partially helpful in solving this problem. In routine diagnostic surgical pathology, it is essential to identify the myoepithelial cell layer by immunohistochemistry to distinguish between an in situ and invasive breast carcinomas and when establishing the presence of microinvasion. The purpose of this study was to evaluate the role of myoepithelial cell layer expression in difficult cases of cutaneous adnexal carcinomas in which histologically it was challenging to separate them from MCS. We studied 38 adnexal carcinomas and evaluated them for myoepithelial markers to confirm the primary nature of the neoplasm. The used markers to search for myoepithelial cell layer retention included calponin, p63, and smooth muscle actin. Of the 38 cases, we found that 13 cases showed myoepithelial layer retention, confirming the primary cutaneous origin of the neoplastic process. The results of our study suggest that the presence of an identifiable retention of the myoepithelial cell layer in adnexal carcinomas could be a useful adjunct observation in the diagnosis of primary adnexal carcinomas, especially in the clinical setting of a questionable primary adnexal versus metastatic neoplasm.

A multicenter study of interobserver variability in pathologic diagnosis of papillary breast lesions on core needle biopsy with WHO classification

BACKGROUND

Papillary breast lesions (PBLs) comprise diverse entities from benign and atypical lesions to malignant tumors. Although PBLs are characterized by a papillary growth pattern, it is challenging to achieve high diagnostic accuracy and reproducibility. Thus, we investigated the diagnostic reproducibility of PBLs in core needle biopsy (CNB) specimens with World Health Organization (WHO) classification.

METHODS

Diagnostic reproducibility was assessed using interobserver variability (kappa value, κ) and agreement rate in the pathologic diagnosis of 60 PBL cases on CNB among 20 breast pathologists affiliated with 20 medical institutions in Korea. This analysis was performed using hematoxylin and eosin (H&E) staining and immunohistochemical (IHC) staining for cytokeratin 5 (CK5) and p63. The pathologic diagnosis of PBLs was based on WHO classification, which was used to establish simple classifications (4-tier, 3-tier, and 2-tier).

RESULTS

On WHO classification, H&E staining exhibited 'fair agreement' (κ = 0.21) with a 47.0% agreement rate. Simple classifications presented improvement in interobserver variability and agreement rate. IHC staining increased the kappa value and agreement rate in all the classifications. Despite IHC staining, the encapsulated/solid papillary carcinoma (EPC/SPC) subgroup (κ = 0.16) exhibited lower agreement compared to the non-EPC/SPC subgroup (κ = 0.35) with WHO classification, which was similar to the results of any other classification systems.

CONCLUSIONS

Although the use of IHC staining for CK5 and p63 increased the diagnostic agreement of PBLs in CNB specimens, WHO classification exhibited a higher discordance rate compared to any other classifications. Therefore, this result warrants further intensive consensus studies to improve the diagnostic reproducibility of PBLs with WHO classification.

A multicenter study of interobserver variability in pathologic diagnosis of papillary breast lesions on core needle biopsy with WHO classification

Background

Papillary breast lesions (PBLs) comprise diverse entities from benign and atypical lesions to malignant tumors. Although PBLs are characterized by a papillary growth pattern, it is challenging to achieve high diagnostic accuracy and reproducibility. Thus, we investigated the diagnostic reproducibility of PBLs in core needle biopsy (CNB) specimens with World Health Organization (WHO) classification.

Methods

Diagnostic reproducibility was assessed using interobserver variability (kappa value, κ) and agreement rate in the pathologic diagnosis of 60 PBL cases on CNB among 20 breast pathologists affiliated with 20 medical institutions in Korea. This analysis was performed using hematoxylin and eosin (H&E) staining and immunohistochemical (IHC) staining for cytokeratin 5 (CK5) and p63. The pathologic diagnosis of PBLs was based on WHO classification, which was used to establish simple classifications (4-tier, 3-tier, and 2-tier).

Results

On WHO classification, H&E staining exhibited ‘fair agreement’ (κ = 0.21) with a 47.0% agreement rate. Simple classifications presented improvement in interobserver variability and agreement rate. IHC staining increased the kappa value and agreement rate in all the classifications. Despite IHC staining, the encapsulated/solid papillary carcinoma (EPC/SPC) subgroup (κ = 0.16) exhibited lower agreement compared to the non-EPC/SPC subgroup (κ = 0.35) with WHO classification, which was similar to the results of any other classification systems.

Conclusions

Although the use of IHC staining for CK5 and p63 increased the diagnostic agreement of PBLs in CNB specimens, WHO classification exhibited a higher discordance rate compared to any other classifications. Therefore, this result warrants further intensive consensus studies to improve the diagnostic reproducibility of PBLs with WHO classification.

An Image Analysis Solution For Quantification and Determination of Immunohistochemistry Staining Reproducibility

Supplemental Digital Content is available in the text.

With immunohistochemical (IHC) staining increasingly being used to guide clinical decisions, variability in staining quality and reproducibility are becoming essential factors in generating diagnoses using IHC tissue preparations. The current study tested a method to track and quantify the interrun, intrarun, and intersite variability of IHC staining intensity. Our hypothesis was that staining precision between laboratory sites, staining runs, and individual slides may be verified quantitatively, efficiently and effectively utilizing algorithm-based, automated image analysis. To investigate this premise, we tested the consistency of IHC staining in 40 routinely processed (formalin-fixed, paraffin-embedded) human tissues using 10 common antibiomarker antibodies on 2 Dako Omnis instruments at 2 locations (Carpinteria, CA: 30 m above sea level and Longmont, CO: 1500 m above sea level) programmed with identical, default settings and sample pretreatments. Digital images of IHC-labeled sections produced by a whole slide scanner were analyzed by a simple commercially available algorithm and compared with a board-certified veterinary pathologist’s semiquantitative scoring of staining intensity. The image analysis output correlated well with pathology scores but had increased sensitivity for discriminating subtle variations and providing reproducible digital quantification across sites as well as within and among staining runs at the same site. Taken together, our data indicate that digital image analysis offers an objective and quantifiable means of verifying IHC staining parameters as a part of laboratory quality assurance systems.

Appendiceal adenocarcinoma with breast metastases

Malignant lesions of the vermiform appendix make up a rare subset of colorectal cancer. While colorectal cancer frequently metastasises to the liver, lung, regional lymph nodes and peritoneum, metastasis to the breast is extremely rare. Here, we describe the case of an 84-year-old woman who had the incidental finding of appendiceal adenocarcinoma following emergency laparoscopic appendectomy. She declined further operative or adjuvant treatment for her disease. She represented 1 year later with metastatic appendiceal adenocarcinoma disease to her left breast. A simple mastectomy for symptomatic treatment was performed. In this report, we describe the first case of appendiceal adenocarcinoma metastases to the breast. Due to its rarity, there is a paucity of evidence related to the management of this condition. The limited evidence is reviewed and discussed.

A case report of multiple bilateral breast metastases after colorectal cancer

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CRC metastasizes commonly to the regional lymph nodes, liver, lung, and rarely to breast.

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The radiologic investigations can play a role in the differentiation between the diagnosis of primary breast cancer and metastases.

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Immunohistochemically, the majority of breast adenocarcinomas are: negative for CDX2 and CK20 and positive for CK7, while colorectal adenocarcinomas are: positive for CDX2 and CK20, and negative for ER, PR, HER2, and CK7.

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The management plan of CRC metastases to the breast is complex and requires a multidisciplinary team.

Introduction and importance

Although primary breast cancer is the most common tumor in women, breast metastases are rare findings. We report the first case in English literature with CRC metastases to the breast and adrenal gland concurrently.

Case presentation

A 42-year-old Caucasian female complained of abdominal pain over the last 3 days. Her history was remarkable for stage 2 colon cancer and she was free of disease for 2 years before the presentation, due to receiving Surgical-chemotherapy. The radiologic investigation showed a well-defined cystic mass in the left adrenal gland and left breast nodule. After adrenalectomy, the diagnosis of the mass was metastatic mucinous adenocarcinoma. During the surgical preparation, bilateral breast lumps were noticed. Histopathology of breast mass showed mucinous adenocarcinoma. Immunohistochemical staining revealed that the neoplastic gland was positive for CDX2, CK20, and P53 mutation and negative for CK7, PR, ER, and HER2. Overall, the diagnosis was metastatic colorectal adenocarcinoma to the breast.

Clinical discussion

Metastatic lesions in the adrenal gland tend to be bilateral with irregular shape. Breast metastases are singular unilateral lesions with predominance in the left breast. Biopsy and immunohistochemistry make the final diagnosis.

The management plan is complex and depends on many factors like the general condition of the patient and the presence of other metastases. However, breast metastases may be a clinical clue to disseminated disease.

Conclusion

Breast metastases should be in the differential diagnosis in patients with a history of colorectal adenocarcinoma, in order to provide the appropriate clinical care.

Precision pathology as applied to breast core needle biopsy evaluation: implications for management

With the shift to de-escalation of therapy for some breast cancers and fewer surgical excisions for high-risk lesions identified on breast imaging studies at one end of the spectrum, and the greater use of neoadjuvant systemic therapy at the other end, pathologists are ever more critical in guiding management decisions for women with breast disease following core needle biopsy. One important consequence of this shift in management paradigms is the elimination of the opportunity for a "second-look" with the excision specimen to confirm or refine the diagnosis rendered on core needle biopsy. Thus, not only is there the imperative for accuracy and precision of core needle biopsy diagnoses, increasingly it is the only opportunity for that diagnosis.

Imbalanced Breast Cancer Classification Using Transfer Learning

Accurate breast cancer detection using automated algorithms remains a problem within the literature. Although a plethora of work has tried to address this issue, an exact solution is yet to be found. This problem is further exacerbated by the fact that most of the existing datasets are imbalanced, i.e., the number of instances of a particular class far exceeds that of the others. In this paper, we propose a framework based on the notion of transfer learning to address this issue and focus our efforts on histopathological and imbalanced image classification. We use the popular VGG-19 as the base model and complement it with several state-of-the-art techniques to improve the overall performance of the system. With the ImageNet dataset taken as the source domain, we apply the learned knowledge in the target domain consisting of histopathological images. With experimentation performed on a large-scale dataset consisting of 277,524 images, we show that the framework proposed in this paper gives superior performance than those available in the existing literature. Through numerical simulations conducted on a supercomputer, we also present guidelines for work in transfer learning and imbalanced image classification.

Breast metastasis from colorectal cancer treated by multimodal therapy: Case report and literature review

INTRODUCTION

Breast metastases from primary colorectal carcinoma are extremely rare, with only 45 cases being reported previously. Since the most common malignancy in the breast and axilla is primary breast cancer regardless of cancer history, non-hematologic metastases may be misdiagnosed initially. Nevertheless, differentiating breast metastases from primary breast cancer is crucial because of their differences in prognosis and management.

PATIENT CONCERNS

We present a case of a 44-year-old Asian woman who noticed a new right breast lump after undergoing surgery and chemotherapy for her primary sigmoid colon cancer.

DIAGNOSIS

Image and immunohistochemistry findings were consistent with breast metastasis from primary colorectal adenocarcinoma.

INTERVENTIONS

The patient underwent breast tumor excision and reinitiated chemotherapy.

OUTCOMES

The patient's disease progressed despite the interventions. She passed away 7 months after the detection of breast metastasis.

CONCLUSION

When a new breast lesion is detected in patients with colorectal cancer history, the physician should consider the possibility of breast metastasis due to the poor prognosis. If a biopsy is necessary, cancer history should be provided to the clinicians to prevent incorrect pathological interpretation. In establishing the diagnosis, certain immunohistochemical markers have been shown to be sensitive and specific in previously reported cases. The combination of tumor excision and chemotherapy was the most common strategy in managing this condition with inconsistent clinical outcomes.

Comparing the Diagnostic Outcomes of Staining Various Breast Lesions with Either Anti-CK 5/6 or Anti-CK 5

Background and Objective:

Anti-CK5/6 monoclonal antibodies have an established role in breast disease diagnosis. Anti-CK5 monoclonal antibodies have recently become commercially available. There has been growing interest in the staining characteristics of anti-CK5 and its potential diagnostic role in place of anti-CK5/6. We aim to compare and contrast the staining characteristics of anti-CK5/6 vs anti-CK5.

Material and Methods:

58 tissue blocks containing 122 different lesions were selected from tissue archives. Two specimens (groups) were taken from each lesion One (group) was stained with anti-CK5 and the other (group) with anti-CK5/6 monoclonal antibodies, using the Streptavidin-biotin immuno-peroxidase method. The two groups of slides were compared and contrasted for lesion staining pattern and for intensity, using light microscopy.

Results:

Results showed that the diagnostic staining pattern was exactly the same in both anti-CK5 and anti-CK5/6 groups, and also showed that anti-CK5, stained most of the lesions more intensely than anti-CK5/6.

Conclusion:

Anti-CK5 performed at least as well (for lesion-pattern staining), and better (for lesion staining intensity) than did anti-CK5/6 in the diagnosis of a wide range of breast tissues and lesions. It may be justified to safely replace anti-CK5/6 with anti-CK5 in future routine clinical use, with resultant diagnostic and economic benefits.

The Immune Microenvironment of Breast Cancer Progression

Inflammation is now recognized as a hallmark of cancer. Genetic changes in the cancer cell are accepted as the match that lights the fire, whilst inflammation is seen as the fuel that feeds the fire. Once inside the tumour, the immune cells secrete cytokines that kick-start angiogenesis to ferry in much-needed oxygen and nutrients that encourage the growth of tumours. There is now irrefutable data demonstrating that the immune contexture of breast tumours can influence growth and metastasis. A higher immune cell count in invasive breast cancer predicts prognosis and response to chemotherapy. We are beginning now to define the specific innate and adaptive immune cells present in breast cancer and their role not just in the progression of invasive disease, but also in the development of pre-invasive lesions and their transition to malignant tumours. This review article focusses on the immune cells present in early stage breast cancer and their relationship with the immunoediting process involved in tumour advancement.

Immunohistochemistry for diagnosis and prognosis of breast cancer: a review

Breast cancer is the most prevalent malignant tumor and main oncologic cause of mortality in women. Although most diagnosis of breast pathology is accomplished using hematoxylin and eosin stained sections, some cases require immunohistochemistry for proper evaluation. We investigated the latter cases including distinctions between ductal and lobular carcinoma, in situ and invasive carcinoma, typical ductal hyperplasia and atypical ductal hyperplasia/ductal carcinoma in situ, papillary and spindle cell lesion assessment, metastasis evaluation, and assessment of prognostic and therapy markers. E-cadherin is used to differentiate ductal and lobular carcinoma; 34βE12, CK8, p120 catenin and β-catenin also produce consistent results. Myoepithelial cell (MEC) stains are used to evaluate in situ and invasive carcinoma; calponin, smooth muscle myosin heavy chain and p63 are sensitive/specific markers. 34βE12 and CK5/6 are positive in ductal hyperplasia, which enables its differentiation from atypical ductal hyperplasia and ductal carcinoma in situ. CK 5/6, ER and MEC markers are consistent options for evaluating papillary lesions. Spindle cell lesions can be assessed using β-catenin, SMA, CD34, p63, CKs and hormone receptors. It is important to differentiate primary carcinomas from metastases; the most commonly used markers to identify breast origin include mammaglobin, GCDFP-15, GATA3 and ER, although none of these is completely sensitive or specific. Immunohistochemistry can be used to evaluate central prognostic and predictive factors including molecular subtypes, HER2, hormone receptors, proliferation markers (Ki-67) and lymph-vascular invasion markers including ERG, CD31, CD34, factor VIII and podoplanin. Owing to the complexity of mammary lesions, diagnosis also depends on each particular situation, evaluation of cytological characteristics revealed by immunochemistry and correlation with histological findings.

Myoepithelial cells are a dynamic barrier to epithelial dissemination

Myoepithelial cells function collectively as a dynamic barrier to the invasion and dissemination of Twist1⁺ luminal epithelial cells and both luminal and basal phenotype breast cancer cells. Barrier function depends on myoepithelial abundance and both smooth muscle contractility and intercellular adhesion within the myoepithelium.

The mammary epithelium is composed of an inner luminal and surrounding myoepithelial cell layer. The presence of cancer cells beyond the myoepithelium defines invasive breast cancer, yet the role of the myoepithelium during invasion remains unclear. We developed a 3D organotypic culture assay to model this process through lineage-specific expression of the prometastatic transcription factor Twist1. We sought to distinguish the functional role of the myoepithelium in regulating invasion and local dissemination. Myoepithelial-specific Twist1 expression induced cell-autonomous myoepithelial cell escape. Remarkably, luminal-specific Twist1 expression was rarely sufficient for escape. Time-lapse microscopy revealed that myoepithelial cells collectively restrain and reinternalize invading Twist1⁺ luminal cells. Barrier function correlated with myoepithelial abundance and required the expression of α-smooth muscle actin and P-cadherin. We next demonstrated that myoepithelial cells can restrain and recapture invasive cancer cells. Our data establish the concept of the myoepithelium as a dynamic barrier to luminal dissemination and implicate both smooth muscle contractility and intercellular adhesion in barrier function.

Precursor Lesions of the Low-Grade Breast Neoplasia Pathway

The nonobligate precursor lesions columnar cell change/hyperplasia and flat epithelial atypia, atypical ductal hyperplasia and atypical lobular hyperplasia, lobular carcinoma in situ, and low-grade ductal carcinoma in situ share morphologic, immunophenotypic, and molecular features supporting the existence of a low-grade breast neoplasia pathway. The practical implication for pathologists is that the identification of one of these lesions should prompt careful search for others. From a clinical management perspective, however, their designation as "precursor lesions" should not be overemphasized, as the risk of progression among the earliest lesions is exceedingly low. Factors determining which lesions will progress remain unknown.

Breast hibernomas: Questioning the embryological origin?

This paper aims to review the concept of hibernomas, with focus on their occurrence, in the breast. It will make reference to a specific case from the Helen Joseph Hospital's Breast Clinic situated in Johannesburg, South Africa. We describe the clinical, radiological and pathological findings in a patient as well as the final diagnosis and treatment (in the form of surgery). This report emphasizes the distinguishable features of hibernomas, and gives guidance as to the surgical approach in large hibernomas stressing the ease of achieving cosmesis without major oncoplastic techniques. More specifically, discussion as whether these rapidly growing, nonrecurring, usually encapsulated growths consisting of brown fat tissue similar to that found in hibernating animals arise from the breast or the underlying muscle is considered.

Merkel cell carcinoma, melanoma, metastatic mimics of breast cancer

Merkel cell carcinoma and melanoma can each occur primarily in breast skin, or metastasize to the breast. The breast is a rare site of metastasis of essentially any and every type of tumor, including carcinomas, sarcomas, and hematolymphoid neoplasms, and 10-30% of breast metastases may represent the initial presentation of disease. Although metastases generally recapitulate histologic features of the primary tumor, they are diagnostically challenging given their rarity and morphologic overlap with breast carcinoma, including special types of breast cancer. Histologic clues may include lack of carcinoma in situ, lack of central elastosis, pattern of infiltration around normal breast structures, yet none of these are specific. Careful correlation with clinical history and judicious use of immunostain panels is essential in approaching these cases.

P40 Immunostain Does Not Outperform p63 as a Myoepithelial Cell Marker in the Daily Practice of Breast Pathology

P40 antibody has been shown to be a more specific squamous and basal cell marker compared with p63. As detection of myoepithelial cells (MECs) plays a critical role in breast pathology, and the fact that p40 targets an isoform of p63, this study was designed to compare these antibodies in a variety of lesions, especially those with an sclerotic stroma and carcinoma in situ. All studied lesions were selected from the daily cases of the 3 authors and stained with p63, p40, and calponin immunohistochemical stains. Thirty-four cases (and 19 internal controls) were included. Seventy percent constituted sclerotic lesions (12 cases) and ductal carcinoma in situ (12 cases). P40 and p63 stained all lesions and showed a similar patchy staining pattern in 50% of ductal carcinoma in situ and sclerotic lesions. Compared with internal controls, p40 and p63 demonstrated decreased staining intensity in up to 70% and 8% of all cases, respectively, with no cross-reactivity with mesenchymal cells and minor cross-reactivity with epithelial cells. In our study, p40 did not outperform p63 as a MEC marker. p40 showed a decreased intensity in a higher number of cases (P<0.0001). In our opinion, p63 continues to be the best nuclear marker for the detection of MECs in the daily practice of breast pathology.

Pathomimetic avatars reveal divergent roles of microenvironment in invasive transition of ductal carcinoma in situ

BACKGROUND

The breast tumor microenvironment regulates progression of ductal carcinoma in situ (DCIS) to invasive ductal carcinoma (IDC). However, it is unclear how interactions between breast epithelial and stromal cells can drive this progression and whether there are reliable microenvironmental biomarkers to predict transition of DCIS to IDC.

METHODS

We used xenograft mouse models and a 3D pathomimetic model termed mammary architecture and microenvironment engineering (MAME) to study the interplay between human breast myoepithelial cells (MEPs) and cancer-associated fibroblasts (CAFs) on DCIS progression.

RESULTS

Our results show that MEPs suppress tumor formation by DCIS cells in vivo even in the presence of CAFs. In the in vitro MAME model, MEPs reduce the size of 3D DCIS structures and their degradation of extracellular matrix. We further show that the tumor-suppressive effects of MEPs on DCIS are linked to inhibition of urokinase plasminogen activator (uPA)/urokinase plasminogen activator receptor (uPAR)-mediated proteolysis by plasminogen activator inhibitor 1 (PAI-1) and that they can lessen the tumor-promoting effects of CAFs by attenuating interleukin 6 (IL-6) signaling pathways.

CONCLUSIONS

Our studies using MAME are, to our knowledge, the first to demonstrate a divergent interplay between MEPs and CAFs within the DCIS tumor microenvironment. We show that the tumor-suppressive actions of MEPs are mediated by PAI-1, uPA and its receptor, uPAR, and are sustained even in the presence of the CAFs, which themselves enhance DCIS tumorigenesis via IL-6 signaling. Identifying tumor microenvironmental regulators of DCIS progression will be critical for defining a robust and predictive molecular signature for clinical use.

Three-dimensional collagen matrix induces a mechanosensitive invasive epithelial phenotype

A critical step in breast cancer progression is local tissue invasion, during which cells pass from the epithelial compartment to the stromal compartment. We recently showed that malignant leader cells can promote the invasion of otherwise non-invasive epithelial follower cells, but the effects of this induced-invasion phenomenon on follower cell phenotype remain unclear. Notably, this process can expose epithelial cells to the stromal extracellular matrix (ECM), which is distinct from the ECM within the normal epithelial microenvironment. Here, we used a 3D epithelial morphogenesis model in which cells were cultured in biochemically and mechanically defined matrices to examine matrix-mediated gene expression and the associated phenotypic response. We found that 3D collagen matrix promoted expression of mesenchymal genes including MT1-MMP, which was required for collagen-stimulated invasive behavior. Epithelial invasion required matrix anchorage as well as signaling through Src, PI3K, and Rac1, and increasingly stiff collagen promoted dispersive epithelial cell invasion. These results suggest that leader cell-facilitated access to the stromal ECM may trigger an invasive phenotype in follower epithelial cells that could enable them to actively participate in local tissue invasion.

From transformation to metastasis: deconstructing the extracellular matrix in breast cancer

The extracellular matrix (ECM) is a guiding force that regulates various developmental stages of the breast. In addition to providing structural support for the cells, it mediates epithelial-stromal communication and provides cues for cell survival, proliferation, and differentiation. Perturbations in ECM architecture profoundly influence breast tumor progression and metastasis. Understanding how a dysregulated ECM can facilitate malignant transformation is crucial to designing treatments to effectively target the tumor microenvironment. Here, we address the contribution of ECM mechanics to breast cancer progression, metastasis, and treatment resistance and discuss potential therapeutic strategies targeting the ECM.

Myoepithelial cells in lobular carcinoma in situ: distribution and immunophenotype

Myoepithelial cells have important physical and paracrine roles in breast tissue development, maintenance, and tumor suppression. Recent molecular and immunohistochemical studies have demonstrated phenotypic alterations in ductal carcinoma in situ-associated myoepithelial cells. Although the relationship of lobular carcinoma in situ (LCIS) and myoepithelial cells was described in 1980, further characterization of LCIS-associated myoepithelial cells is lacking. We stained 27 breast specimens harboring abundant LCIS with antibodies to smooth muscle myosin heavy chain, smooth muscle actin, and calponin. Dual stains for E-cadherin/smooth muscle myosin heavy chain and CK7/p63 were also performed. In each case, the intensity and distribution of staining in LCIS-associated myoepithelial cells were compared with normal breast tissue on the same slide. In 78% of the cases, LCIS-associated myoepithelial cells demonstrated decreased staining intensity for one or more myoepithelial markers. The normal localization of myoepithelial cells (flat against the basement membrane, pattern N) was seen in 96% of LCIS, yet 85% of cases had areas with myoepithelial cell cytoplasm oriented perpendicular to the basement membrane (pattern P), and in 30% of cases, myoepithelial cells appeared focally admixed with LCIS cells (pattern C). This study characterizes detailed architectural and immunophenotypic alterations of LCIS-associated myoepithelial cells. The finding of variably diminished staining favors application of several myoepithelial immunostains in clinical practice. The interaction of LCIS with myoepithelial cells, especially in light of the perpendicular and central architectural arrangements, deserves further mechanistic investigation.

Ras protein expression as a marker for breast cancer

Breast cancer, the most common neoplasm in women of all ages, is the leading cause of cancer-related mortality in women worldwide. Markers to help to predict the risk of progression and ultimately provide non-surgical treatment options would be of great benefit. At present, there are no available molecular markers to predict the risk of carcinoma in situ progression to invasive cancer; therefore, all women diagnosed with this type of malignancy must undergo surgery. Breast cancer is a heterogeneous complex disease, and different patients respond differently to different treatments. In breast cancer, analysis using immunohistochemical markers remains an essential component of routine pathological examinations, and plays an import role in the management of the disease by providing diagnostic and prognostic strategies. The aim of the present study was to identify a marker that can be used as a prognostic tool for breast cancer. For this purpose, we firstly used an established breast cancer model. MCF-10F, a spontaneously immortalized breast epithelial cell line was transformed by exposure to estrogen and radiation. MCF-10F cells were exposed to low doses of high linear energy transfer (LET) α particles (150 keV/μm) of radiation, and subsequently cultured in the presence of 17β-estradiol. Three cell lines were used: i) MCF-10F cells as a control; ii) Alpha5 cells, a malignant and tumorigenic cell line; and iii) Tumor2 cells derived from Alpha5 cells injected into nude mice. Secondly, we also used normal, benign and malignant breast specimens obtained from biopsies. The results revealed that the MCF-10F cells were negative for c-Ha-Ras protein expression; however, the Alpha5 and Tumor2 cell lines were positive for c-Ha-Ras protein expression. The malignant breast samples were also strongly positive for c-Ha-Ras expression. The findings of our study indicate that c-Ha-Ras protein expression may be used as a marker to predict the progression of breast cancer; this marker may also ultimately provide non-surgical treatment options for patients who are at a lower risk.

Use of Immunohistochemical Stains in Epithelial Lesions of the Breast

BACKGROUND

During the last few decades, immunohistochemistry (IHC) has become an integral part of pathology. Although hematoxylin and eosin (H & E) stain remains the fundamental basis for diagnostic pathology of the breast, IHC stains provide useful and sometimes vital information. Moreover, considering the role of hormonal therapy in hormone receptor-positive breast tumors, as well as the availability of targeted chemotherapeutic agents for HER2-positive cases, IHC studies represent a major part of workups.

METHODS

A literature search was performed to explore the uses of IHC stains related to the diagnoses of breast lesions and prognostic/predictive information.

RESULTS

Selective use of IHC stains in conjunction with H & E examination helps resolve most diagnostic issues encountered by surgical pathologists during their day-to-day practice. Pathologists should be familiar with the use of each immunostain and its limitations to avoid interpretative errors.

CONCLUSIONS

IHC stains help guide the differential diagnosis of challenging epithelial lesions of the breast. They should be selectively and judiciously used and their findings must be interpreted with the differential diagnoses in mind and with an understanding of possible pitfalls.

Intracystic Papillary Carcinoma in a Man with Gynecomastia

Male breast cancer is a rare disease in the male breast whereas gynecomastia is quite common. An elevation of the estrogen-to-androgen ratio increases the risk of both of these diseases. However, a connection between gynecomastia and subsequent breast cancer development is controversial and unclear. Imaging studies including mammography and ultrasound provide valuable information in leading to a correct diagnosis. Traditionally, intracystic papillary carcinoma, also known as encapsulated papillary carcinoma, has been considered a form of ductal carcinoma in situ. Recent immunohistochemical studies, demonstrating an absence of myothelium, in many cases would be more compatible with the diagnosis of invasive malignancy. However, intracystic papillary carcinoma holds a favorable prognosis with local therapy alone. We report a case of intracystic papillary carcinoma in a male patient with long-standing gynecomastia diagnosed eight years prior by mammography. The patient presented with a breast lump on both occasions. Current work-up consisted of both mammography and ultrasound. Ultrasound provided key information revealing a complex mass requiring further evaluation. Ultrasound-guided core needle biopsy revealed intracystic papillary carcinoma with confirmation upon surgical excision.

Myoepithelial cell differentiation markers in ductal carcinoma in situ progression

We describe a preclinical model that investigates progression of early-stage ductal carcinoma in situ (DCIS) and report that compromised myoepithelial cell differentiation occurs before transition to invasive disease. Human breast cancer MCF10DCIS.com cells were delivered into the mouse mammary teat by intraductal injection in the absence of surgical manipulations and accompanying wound-healing confounders. DCIS-like lesions developed throughout the mammary ducts with full representation of human DCIS histologic patterns. Tumor cells were incorporated into the normal mammary epithelium, developed ductal intraepithelial neoplasia and DCIS, and progressed to invasive carcinoma, suggesting the model provides a rigorous approach to study early stages of breast cancer progression. Mammary glands were evaluated for myoepithelium integrity with immunohistochemical assays. Progressive loss of the myoepithelial cell differentiation markers p63, calponin, and α-smooth muscle actin was observed in the mouse myoepithelium surrounding DCIS-involved ducts. p63 loss was an early indicator, calponin loss intermediate, and α-smooth muscle actin a later indicator of compromised myoepithelium. Loss of myoepithelial calponin was specifically associated with gain of the basal marker p63 in adjacent tumor cells. In single time point biopsies obtained from 16 women diagnosed with pure DCIS, a similar loss in myoepithelial cell markers was observed. These results suggest that further research is warranted into the role of myoepithelial cell p63 and calponin expression on DCIS progression to invasive disease.

Application of immunohistochemistry in breast pathology: a review and update

CONTEXT

Immunohistochemistry is a valuable tool in routine breast pathology, used for both diagnostic and prognostic parameters. The diagnostic immunomarkers are the scope of this review. Most breast lesions can be diagnosed on routine hematoxylin-eosin sections; however, in several scenarios, such as morphologically equivocal cases or metastatic tumors of unknown primary, the appropriate application of immunohistochemistry adds true value in reaching an accurate diagnosis.

OBJECTIVE

To evaluate the diagnostic utility of the most commonly studied immunomarkers in the field of breast pathology by review of the literature, using the database of indexed articles in PubMed (US National Library of Medicine, Bethesda, Maryland) from 1976 to 2013.

DATA SOURCES

Literature review, and author's research data and personal practice experience.

CONCLUSIONS

The appropriate use of immunohistochemistry by applying a panel of immunomarkers and using a standardized technical and interpretational method will complement the morphologic assessment and aid in the accurate classification of difficult breast lesions and the identification of metastasis from a breast primary.

The clinical use of a P63/cytokeratin7/18/cytokeratin5/14 antibody cocktail in diagnostic breast pathology

An antibody cocktail directed against p63, cytokeratin (CK)5/14, and CK7/18 is reported to be useful in distinguishing noninvasive from invasive breast lesions and for the characterization of intraductal epithelial proliferations. However, limited studies evaluate its use in clinical practice. A retrospective review of breast material at a university medical center identified cases that were immunostained with the above antibody cocktail. Additional p63 immunostaining alone was performed to further determine the utility of the antibody cocktail in the evaluation of invasion. Of 50 breast cases identified, the antibody cocktail was used to confirm or exclude invasion in 44 (88%). Twenty-two (50%) of these had easily identifiable p63/CK5/14-positive myoepithelial cells, whereas the remainder lacked such staining, confirming the diagnosis of invasive carcinoma. In 27 cases with available diagnostic material for additional p63 immunostaining, the cocktail better highlighted myoepithelial cells by staining nuclei and cytoplasm. Easier identification of invasion was also facilitated by CK7/18 expression in invasive foci, especially those composed of single cells. Ten cases were immunostained to help determine the nature of an intraductal proliferation. The cocktail demonstrated a mosaic staining pattern of both CK7/18- and CK5/14-positive epithelial cells in 3 (30%) cases consistent with usual hyperplasia; homogenous CK7/18 expression in the remaining cases supported the diagnosis of atypical ductal hyperplasia or carcinoma in situ. In summary, the p63/CK7/18/CK5/14 cocktail stain appears to be a useful tool in diagnostic breast pathology, in the evaluation of possible invasion, particularly in the setting of minute foci of invasion as well as in epithelial proliferations.

Illuminating breast cancer invasion: diverse roles for cell-cell interactions

Metastasis begins when tumors invade into surrounding tissues. In breast cancer, the study of cell interactions has provided fundamental insights into this complex process. Powerful intravital and 3D organoid culture systems have emerged that enable biologists to model the complexity of cell interactions during cancer invasion in real-time. Recent studies utilizing these techniques reveal distinct mechanisms through which multiple cancer cell and stromal cell subpopulations interact, including paracrine signaling, direct cell-cell adhesion, and remodeling of the extracellular matrix. Three cell interaction mechanisms have emerged to explain how breast tumors become invasive: epithelial-mesenchymal transition, collective invasion, and the macrophage-tumor cell feedback loop. Future work is needed to distinguish whether these mechanisms are mutually exclusive or whether they cooperate to drive metastasis.

Ductal carcinoma in situ of the breast: current concepts and future directions

CONTEXT

In situ carcinomas of the breast constitute 15% to 30% of all newly diagnosed breast cancer cases; 80% of these in situ lesions belong to the ductal carcinoma in situ (DCIS) category. Similar to invasive breast carcinomas, DCIS is not a single disease but rather many distinct diseases with different histopathologic and molecular characteristics, a propensity to progress to invasive disease, and differential response to treatment.

OBJECTIVE

To review the classic pathologic parameters of clinical significance and the differential diagnosis of the DCIS lesions, present our new understanding of the importance of biomarkers, and discuss innovative approaches for targeted therapy in DCIS.

DATA SOURCES

Extensive review of the relevant peer-reviewed literature.

CONCLUSIONS

In DCIS, improved understanding of the underlying biologic pathways of tumor progression is expected to lead to more accurate classification and innovative targeted treatment approaches for the management of these lesions.

Accurate assessment of HER2 gene status for invasive component of breast cancer by combination of immunohistochemistry and chromogenic In Situ hybridization

The specimens of ductal carcinoma in situ (DCIS) with early invasion, and specimens collected by core needle biopsy (CNB) tend to contain limited amount of invasive component, so it is imperative to explore a new technique which can assess HER2 gene status accurately for the limited invasive cancer component in these specimens. Dual staining technique of combining immunohistochemistry (IHC) for myoepithelial cells and single or dual probe chromogenic in situ hybridization (CISH) for HER2 gene was performed on routinely processed paraffin sections from 20 cases diagnosed as having DCIS with invasive cancer. Among them, 10 had fluorescence in situ hybridization (FISH)-confirmed amplification of HER2 and 10 had FISH-confirmed non-amplification of HER2. We successfully detected HER2 genetic signals and myoepithelial IHC markers (SMM-HC or CK5/6) simultaneously on a single section in all 20 specimens. Myoepithelial markers and HER2 signals detected by dual staining assay were consistent with those by individual technique performed alone. HER2 gene amplification results determined by dual staining assay were 100% consistent with those of FISH. Dual staining technique which allows simultaneous detection of myoepithelial marker protein and cancerous HER2 gene is feasible, and it has potential to be used in clinical practice for effective determination of HER2 amplification in limited invasive component.

Regression of ductal carcinoma in situ after treatment with acupuncture

This report describes a case of ductal carcinoma in situ (DCIS) that regressed after treatment with acupuncture, Chinese herbs, and other complementary and alternative medicine (CAM). The natural history of DCIS remains to be elucidated, and it is unclear whether all DCIS cases progress to invasive breast cancer. Surgery plus radiation therapy or mastectomy is recommended for women in whom this potentially nonprogressive cancer is detected. This case supports the developing trend toward active surveillance in lieu of breast-disfiguring surgery and offers evidence that CAM therapies may be of value in preventing progression of DCIS to invasive breast cancer.

CD10 expression by melanoma cells is associated with aggressive behavior in vitro and predicts rapid metastatic progression in humans

BACKGROUND

No biological or molecular marker of primary melanoma tumor cells has been shown to predict clinical outcome in melanoma.

OBJECTIVE

To determine whether CD10, CD133, nestin and CD20 may evaluate the prognosis of melanoma.

METHODS

The differential expression of these molecules was assessed in pairs of cell lines. We evaluated, by both immunohistochemical staining and RT-qPCR, their expression in a cohort of 32 patients (68 samples) with a history of metastatic melanoma, divided into two groups according to their clinical outcome profile.

RESULTS

CD10 over expression in cancer cell lines was associated with more aggressive behavior in vitro. A CD10-positive staining was more frequent in patients in the "rapidly progressive" group than those in the "long survivor" group (23/35 versus 2/18, p<10(-4)). CD10 expression was associated with a lower median overall survival (1.15 year - IQR: [0.50-2.58] versus 4.27 - IQR: [1.66-6.33]; p=10(-4)). The Odds Ratio of displaying a "rapidly progressive" melanoma when tumor cells expressed CD10 was 15 (95% confidence interval: [3-78]). After adjusting for confounding factors, CD10 expression in melanoma tumor cells remained associated with an increased risk of death and more rapid disease progression (p=6×10(-4); HR=3.71).

CONCLUSION

CD10 may predict clinical outcome in melanoma patients.

Tumor microenvironment and breast cancer progression: a complex scenario

It is now widely accepted that the development and progression of a tumor toward the malignant phenotype is highly dependent on interactions between tumor cells and the tumor microenvironment. Different components of the tumor microenvironment may have stimulatory or inhibitory effects on tumor progression by regulating the gene expression repertoire in tumor cells and stromal cells. This review analyzes novel research findings on breast cancer progression, discussing acquisition of the metastatic phenotype in breast disease in relation to different aspects of cross-talk among components of the tumor microenvironment. Knowledge of the interaction of all of these factors would contribute to elucidating the mechanisms that disrupt regulatory/signaling cascades and downstream effects in breast cancer.

CD44 Promotes Epithelial Mammary Gland Development and Exhibits Altered Localization during Cancer Progression

The basal cell layer has emerged as a critical player in cancer progression, and understanding the molecular contribution of specific cell types is important in treatment and prevention. The adhesion receptor CD44, which mediates epithelial-stromal and cell-cell interactions, has been shown to both promote and suppress tumor progression. To better understand the normal function of CD44, we have investigated its role in mouse mammary gland development and its expression in human breast and prostate cancer. We have found that CD44 is expressed in the myoepithelium of the developing mammary gland and modulates ductal development of FVB/N mice. The loss of CD44 results in defective luminal-myoepithelial cell-cell adhesion and promotes the mixing of luminal and myoepithelial layers, disrupting epithelial bilayer organization, and CD44-null mice experience delayed ductal outgrowth and impaired terminal end bud formation. The myoepithelial expression of CD44 is also relevant to its expression in cancer, as CD44 is expressed in the basal cells of early-stage breast and prostate cancer but exhibits altered localization with increasing tumorigenicity and is strongly expressed by tumor epithelium.

Single-domain antibodies: a versatile and rich source of binders for breast cancer diagnostic approaches

Noninvasive early detection of breast cancer through the use of biomarkers is urgently needed since the risk of recurrence, morbidity, and mortality is closely related to disease stage at the time of primary surgery. A crucial issue in this approach is the availability of relevant markers and corresponding monoclonal antibodies suitable for the development of effective immunodiagnostic modalities. The identification of such markers from human pathological lesions and the isolation of specific antibodies using conventional approaches remain major challenges. Camelids produce functional antibodies devoid of light chains in which the single N-terminal domain of the heavy chain is fully capable of antigen binding. When produced as an independent domain, these so-called single-domain antibody fragments (sdAbs) or nanobodies have several advantages for biotechnological applications owing to their unique properties of size (13 kDa), stability, solubility, and expression yield. In this work, we have generated phage display libraries from animals immunized with breast cancer biopsies. These libraries were used to isolate sdAbs against known and relevant antigens such as HER2, or several cancer-specific sdAbs against unknown targets. We describe the identification of one these targets, cytokeratin 19, using affinity purification in combination with mass spectrometry. Some of these sdAbs were used in several straightforward diagnostic applications such as immunohistochemical analysis of tumor samples, multiplexed cytometric bead array analysis of crude samples, or an immune enrichment procedure of rare cells. Here, we demonstrate that phage display-based selection of single-domain antibodies is an efficient and high-throughput compatible approach to generate binders with excellent characteristics for the fast development of diagnostic and prognostic modalities.

Distribution of aldehyde dehydrogenase 1-positive stem cells in benign mammary tissue from women with and without breast cancer

AIMS

Aldehyde dehydrogenase 1 (ALDH1) in female breast tissue has been linked to stem cells, but little is known about the benign cellular organization in situ. We investigated the distribution of ALDH1-immunoreactive (ALDH1+) cells in histomorphologically benign breast tissue from 28 women with or without breast cancer.

METHODS AND RESULTS

ALDH1+ cells were detected in benign tissue of women aged 20-72 years, located most commonly at the luminal and intermediate ductular levels and in the stroma. ALDH1+ cell populations and Ki67+ cell populations were present in separate ductules, both cell types rarely showing epithelial differentiation. ALDH1+ cells were non-reactive to Ki67 and oestrogen receptor. Stromal round/oval ALDH1+ non-leukocyte cells in both age groups expressed contractile protein. There was a lower concentration of luminal and intermediate ductular ALDH1+ cells in postmenopausal women than in premenopausal women, and in cancer patients than in non-cancer patients, and a higher concentration in women receiving exogenous hormones.

CONCLUSIONS

This study provides further evidence for the stem cell character of ALDH1+ cells, here in benign breast tissue of cancer and non-cancer patients throughout non-lactating adult life, and contributes evidence of benign stromal ALDH1+ cells. The distribution of ductular ALDH1+ stem cells appears to be influenced by hormonal status.

Mechanobiology of tumor invasion: engineering meets oncology

The physical sciences and engineering have introduced novel perspectives into the study of cancer through model systems, tools, and metrics that enable integration of basic science observations with clinical data. These methods have contributed to the identification of several overarching mechanisms that drive processes during cancer progression including tumor growth, angiogenesis, and metastasis. During tumor cell invasion - the first clinically observable step of metastasis - cells demonstrate diverse and evolving physical phenotypes that cannot typically be defined by any single molecular mechanism, and mechanobiology has been used to study the physical cell behaviors that comprise the "invasive phenotype". In this review, we discuss the continually evolving pathological characterization and in vitro mechanobiological characterization of tumor invasion, with emphasis on emerging physical biology and mechanobiology strategies that have contributed to a more robust mechanistic understanding of tumor cell invasion. These physical approaches may ultimately help to better predict and identify tumor metastasis.