Reliability of histological malignancy grade, ER and HER2 status on core needle biopsy vs surgical specimen in breast cancer

Concordance of immunohistochemistry for predictive and prognostic factors in breast cancer between biopsy and surgical excision: a single-centre experience and review of the literature

PURPOSE

Accurate evaluation of breast cancer on bioptic samples is of fundamental importance to guide therapeutic decisions, especially in the neoadjuvant or metastatic setting. We aimed to assess concordance for oestrogen receptor (ER), progesterone receptor (PR), c-erbB2/HER2 and Ki-67. We also reviewed the current literature to evaluate our results in the context of the data available at present.

METHODS

We included patients who underwent both biopsy and surgical resection for breast cancer at San Matteo Hospital, Pavia, Italy, between January 2014 and December 2020. ER, PR, c-erbB2, and Ki-67 immunohistochemistry concordance between biopsy and surgical specimen was evaluated. ER was further analysed to include the recently defined ER-low-positive in our analysis.

RESULTS

We evaluated 923 patients. Concordance between biopsy and surgical specimen for ER, ER-low-positive, PR, c-erbB2 and Ki-67 was, respectively, 97.83, 47.8, 94.26, 68 and 86.13%. Cohen's κ for interobserver agreement was very good for ER and good for PR, c-erbB2 and Ki-67. Concordance was especially low (37%) in the c-erbB2 1 + category.

CONCLUSION

Oestrogen and progesterone receptor status can be safely assessed on preoperative samples. The results of this study advise caution in interpreting biopsy results regarding ER-low-positive, c-erbB2/HER and Ki-67 results due to a still suboptimal concordance. The low concordance for c-erbB2 1 + cases underlines the importance of further training in this area, in the light of the future therapeutic perspectives.

Concordance of breast cancer biomarker testing in core needle biopsy and surgical specimens: A single institution experience

BACKGROUND

Accurate diagnostic biomarker testing is crucial to treatment decisions in breast cancer. Biomarker testing is performed on core needle biopsies (CNB) and is often repeated in the surgical specimen (SS) after resection. As differences between CNB and SS testing may alter treatment decisions, we evaluated concordance between CNB and SS as well as associated changes in treatment and clinical outcomes.

METHODS

We performed a retrospective analysis of breast cancer patients at our institution between January 2010 and May 2020. Concordance between CNB and SS was assessed for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) by immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH). Survival in patients, including recurrence, metastatic recurrence, and death, were assessed using chi-squared likelihood ratio.

RESULTS

In total, 961 patients met eligibility criteria. Concordance, minor discordance, total concordance (concordance plus minor discordance), and major discordance between CNB and SS were reported for ER (87.7%, 9.2%, 90.8%, and 2.9%), PR (58.1%, 29.1%, 87.2%, and 12.8%), and HER2 IHC (52.5%, 20.9%, 73.4%, 26.6%), respectively. HER2 FISH concordance and major discordance were 58.5% and 1.2%, respectively. Of major discordance, ER (48.2%, p < 0.001) and HER2 FISH (50.0%) led to more management changes than HER2 IHC (2.4%, p = 0.04) and PR (1.6%, p = 0.10). Patients with ER major discordance had increased risk of death (6.7% concordance vs. 22.2% major discordance, p = 0.004).

CONCLUSION

Overall, retesting ER and HER2 was more clinically beneficial than retesting PR. To aid decision-making and minimize healthcare costs, we propose patient-centered guidelines on retesting biomarker profiles.

Preoperative prediction of histologic grade in invasive breast cancer by using contrast-enhanced spectral mammography-based radiomics

OBJECTIVE

To develop and validate a radiomics model based on contrast-enhanced spectral mammography (CESM), and preoperatively discriminate low-grade (grade I/II) and high-grade (grade III) invasive breast cancer.

METHOD

A total of 205 patients with CESM examination and pathologically confirmed invasive breast cancer were retrospectively enrolled. We randomly divided patients into two independent sets namely, training set (164 patients) and test set (41 patients) with a ratio of 8:2. Radiomics features were extracted from the low-energy and subtracted images. The least absolute shrinkage and selection operator (LASSO) logistic regression were established for feature selection, which were then utilized to construct three classification models namely, low energy, subtracted images and their combined model to discriminate high- and low-grade invasive breast cancer. Receiver operator characteristic (ROC) curves were used to confirm performance of three models in training set. The clinical usefulness was evaluated by using decision curve analysis (DCA). An independent test set was used to confirm the discriminatory power of the models. To test robustness of the result, we used 100 times LGOCV (leave group out cross validation) to validate three models.

RESULTS

From initial radiomics feature pool, 17 and 11 features were selected for low-energy image and subtracted image, respectively. The combined model using 28 features showed the best performance for preoperatively evaluating the histologic grade of invasive breast cancer, with an area under the curve, AUC = 0.88, and 95%confidence interval [CI] 0.85 to 0.92 in the training set and AUC = 0.80 (95%CI 0.67 to 0.92) in the test set. The mean AUC of LGOCV is 0.82.

CONCLUSIONS

CESM-based radiomics model is a non-invasive predictive tool that demonstrates good application prospects in preoperatively predicting histological grade of invasive breast cancer.

Utility of Human Epidermal Growth Factor Receptor 2 (HER2) Retesting of Histologic Grade 3 Invasive Breast Carcinomas

BACKGROUND

American Society of Clinical Oncology and College of American Pathologists guidelines recommend repeated evaluation of human epidermal growth factor receptor 2 (HER2) status on surgical specimens from patients with a diagnosis by core-needle biopsy of Grade 3, HER2-negative invasive tumors of the breast. However, there are limited data to support reflexive testing.

OBJECTIVE

To evaluate the utility of HER2 retesting of histologic Grade 3, HER2-negative invasive breast carcinomas.

METHODS

We evaluated 78 patients from Kaiser Permanente East Bay in whom Grade 3, HER2-negative invasive breast carcinoma was diagnosed between 2015 and 2017 by core biopsy, to compare HER2 status on core biopsy vs excisional biopsy specimen. The HER2 status was determined by immunohistochemistry, fluorescent in situ hybridization, or both. All patients were retested for HER2 status on surgical specimen according to the aforementioned guidelines. Recipients of neoadjuvant chemotherapy were excluded.

RESULTS

One of the 78 patients demonstrated negative-to-positive status discordance between core biopsy and surgical specimens and was treated with trastuzumab. One patient was HER2 negative by core biopsy and was HER2 equivocal by immunohistochemical and fluorescent in situ hybridization evaluation of the surgical specimen. Seventy-six patients demonstrated concordant HER2 status between core biopsy and surgical specimens.

CONCLUSION

The rate of clinically significant HER2 status discordance between core biopsy and surgical specimens in patients with Grade 3 breast carcinoma is low. However, given the dramatically improved survival conferred by trastuzumab therapy, our findings support reflex HER2 testing of surgical specimens for patients with core biopsy-diagnosed HER2-negative breast carcinoma.

Core needle biopsy as an alternative to whole section in IHC4 score assessment for breast cancer prognostication

AIMS

IHC4 score, based on expression of four routine markers (oestrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2) and proliferation marker, Ki67), is a recently developed, cost-effective prognostic tool in breast cancer. Possibly, the score may be useful also in advanced diseases where only core needle biopsy (CNB) is available and neoadjuvant therapy. However, its studies on CNB are scant. This study examined whether IHC4 score assessment on CNB is comparable to that from whole section (WS).

METHODS

Immunohistochemical (IHC) analysis was performed for ER, PR, HER2 and Ki67 on 108 paired CNB and WS to evaluate IHC4 score (with follow-up range 1-230 months and 5 relapse/death). Concordance between the two was examined. Factors that affected the concordance were analysed. Additionally, IHC4 score was compared with Nottingham Prognostic Index (NPI).

RESULTS

There was moderate concordance between IHC4 score on CNB and WS (all cases: κ=0.699, p<0.001; ER+ cases: κ=0.595, p<0.001). Among the IHC4 components, concordance for HER2 was the poorest (κ=0.178, p<0.001 in all cases; ER+ cases: κ=0.082, p<0.097). Significant factors affecting concordance between CNB and WS included number of cores, total core length and percentage of tumour cells in cores (p≤0.030), indicating the importance of sufficient sampling. Interestingly, the concordance was also affected by patients' age (p=0.039). There was poor agreement between IHC4 score and NPI (κ≤0.160).

CONCLUSION

Our results suggested that IHC4 score can be used on adequately sampled CNB. Its poor agreement with NPI highlights the independence of the two factors.

Are fine-needle aspiration biopsy-derived cell blocks a useful surrogate for tissue samples in breast cancer?

AIMS

The diagnosis of breast cancer (BC) is based on clinical examination in combination with imaging, and confirmed by pathological assessment of core needle biopsy or fine-needle aspiration biopsy (FNAB). The biological profile of the lesion is needed to define the prognosis and establish therapy. Given the importance of an early and minimally invasive diagnosis, we aimed to verify whether the biological features detected in FNAB-derived cytological material reflect the biological characteristics of surgical samples.

METHODS AND RESULTS

We used immunohistochemistry and fluorescence in-situ hybridisation to study a panel of conventional biomarkers [oestrogen receptor (ER), progesterone receptor (PgR), Ki67, and human epidermal growth factor receptor 2 (HER2)] in FNAB-derived cytological samples included in cell blocks of 93 BC patients, and compared the results with those obtained from histological evaluation of the same parameters in surgical samples. Median immunopositive values of ER, PgR and Ki67 were similar in cell blocks and surgical samples. The concordance rates of ER and PgR between FNAB-derived cell blocks and histological samples were 98% and 84%, respectively. The concordance rates of Ki67 and HER2 between the two sample types were 90% and 96%, respectively. Tumour subtype classification for triple-negative and HER2-positive BCs in FNAB-derived cell blocks was always concordant with the subtype determined in surgical material.

CONCLUSIONS

We demonstrated that biological marker determination in FNAB-derived cell blocks is feasible, and provides useful information and comparable results to those obtained with histological evaluation. Given the low cost of the procedure and its minimal impact on patients, we believe that cytological samples could be used as an alternative to tissue samples for early BC biomarker evaluation.

The Reliability of Core-Needle Biopsy in Assessment of Hormone Receptor, HER2, and Ki-67 in Breast Carcinoma

Objective:

The purpose of this study was to compare the estrogen receptor (ER), progesterone receptor (PgR), and human epidermal growth factor receptor 2 (HER2) status and Ki-67 index by immunohistochemical (IHC) analysis in breast carcinoma to determine the level of concordance between core-needle biopsy (CNB) and surgical specimens.

Summary of Background:

Accurate preoperative diagnosis of a breast lesion has recently been considered essential to the treatment strategy to achieve optimal treatment without delay. However, the reliability of using CNB specimens for IHC assessment is in relatively small number of cases and differing results between previous studies.

Methods:

The patients included in this study were 255 patients with primary breast carcinoma who had CNB and subsequent surgical resection at the Hospital of Dokkyo Medical University between 2010 and 2016. We compare the ER, PgR, HER2 status, and Ki-67 index by IHC analysis in breast carcinoma between CNB and surgical specimens.

Results:

There was a concordance rate between the ER, PgR, HER2, and Ki-67 IHC assessment of CNB and surgical specimens in 99.0%, 92.1%, 86.3%, and 91.5%, respectively. We also found small numbers of discordant cases in the estimation for which a discrepancy in determination led to a change in treatment.

Conclusions:

Our results do not entirely invalidate the use of CNB for assessment if they are the only source of tumor tissue available, but suggest a more cautious approach in their interpretation when clinical decisions are being made.

Let us cut to the core: is core biopsy enough for subcentimeter breast cancer?

BACKGROUND

Breast conservation therapy has become a preferred method of treating early-stage breast cancer. As care continues to evolve, certain lesions allowed less invasive treatment options. A simplified explanation of early breast cancer care is detection, biopsy, surgery, and adjuvant therapy. The authors look to challenge that algorithm for a specific type of disease.

METHODS

A retrospective review was performed to identify all subcentimeter breast cancer that underwent surgery after core biopsy. These cases (n = 115) were analyzed for biopsy technique and outcome of final surgical excision to find when no residual disease was found on final pathology, potentially rendering the surgical resection an unneeded procedure.

RESULTS

The authors found that 17 of 115 patients (14.8%) who underwent biopsy for subcentimeter breast cancer had no residual disease found on final surgical resection. Although the subsets were small, the largest core needle resulted in negative pathology two of three times, while the smallest gauge, never resulted in negative resection at time of surgery.

CONCLUSIONS

Nearly, fifteen percent of patients were found to have no residual disease on final surgical pathology. These results were obtained when the radiologist was simply trying to get tissue diagnosis. The authors postulate that this percentage could be even higher if protocols were initiated to biopsy these small lesions with larger core biopsies and possibly alleviate the need for formal surgery in these specific, small lesion.

Comparison of Core Needle Biopsy and Excision Specimens for the Accurate Evaluation of Breast Cancer Molecular Markers: a Report of 1003 Cases

In this study, we compared the accuracy of marker evaluation in core needle biopsy (CNB) specimens versus excision specimens (ESs) from breast cancer patients. This retrospective study used data collected from the breast cancer database at the West China Hospital, China. Immunohistochemistry (IHC) results from CNB specimens and ESs were compared, using estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), and Ki-67 as markers. Molecular subtyping and endocrine therapy usage correlations based on CNB samples and ESs were evaluated. The results obtained from CNB samples and ESs exhibited substantial agreement for the detection of ER (κ = 0.522), PR (κ = 0.441), and HER2 (κ = 0.451), and also influenced endocrine therapy usage. Fair and poor correlations were observed for Ki-67 staining and molecular subtyping (κ = 0.195), respectively. This disagreement might be attributable to a combination of heterogeneity and large tumor size. This study indicates that the discordance rate in molecular marker staining between CNB specimens and ESs is significant enough that results obtained with CNB specimens should be used cautiously or verified using ESs.

Impact of molecular subtypes classification concordance between preoperative core needle biopsy and surgical specimen on early breast cancer management: Single-institution experience and review of published literature

BACKGROUND

Core needle biopsy (CNB) plays a crucial role as diagnostic tool for breast cancer (BC). The characterization of biomarkers status before surgical treatment is crucial when primary systemic therapy is a therapeutic option. The aim of this analysis was to report concordance between preoperative CNB and surgical specimen (SS) in evaluating biomarkers and molecular subtypes.

METHODS

Data have been collected from a cohort of 101 patients affected by early BC treated at Careggi Florence University Hospital, between January 2014 and March 2015. The conformity between molecular subtype classification was tested using kappa (κ) test.

RESULTS

Mean age was 57.5 years (range 29-86). There was concordance between the estrogen receptor (ER) assessment on CNB and SS in 95 cases (94.1%). Concordance of the progesterone receptor (PgR) assessment was observed in 89 cases (88.1%). Concordance for detecting immunohistochemistry-assessed BC molecular subtypes was 87.1% (κ = 0.78). Concerning Ki-67 evaluation, we report a concordance rate of 88.1% (κ = 0.68). The evaluation of luminal A plus luminal B/HER negative subgroup showed a κ-value of 0.65.

CONCLUSIONS

CNB showed good accuracy in evaluating hormonal receptors status, HER2, and BC molecular subtypes. Evaluation of Ki67 status was less accurate than other biomarkers; therefore, we recommend that it should be detected both on CNB and SS samples, especially in hormonal positive HER2 negative tumors, in order to avoid a misclassification of tumor subtypes that could lead to an omission of potential effective systemic therapy.

A prospective comparison of ER, PR, Ki67 and gene expression in paired sequential core biopsies of primary, untreated breast cancer

BACKGROUND

Sequential biopsy of breast cancer is used to assess biomarker effects and drug efficacy. The preoperative "window of opportunity" setting is advantageous to test biomarker changes in response to therapeutic agents in previously untreated primary cancers. This study tested the consistency over time of paired, sequential biomarker measurements on primary, operable breast cancer in the absence of drug therapy.

METHODS

Immunohistochemistry was performed for ER, PR and Ki67 on paired preoperative/operative tumor samples taken from untreated patients within 2 weeks of each other. Microarray analysis on mRNA extracted from formalin fixed paraffin embedded cores was performed using Affymetrix based arrays on paired core biopsies analysed using Ingenuity Pathway Analysis (IPA) and Gene Set Analysis (GSA).

RESULTS

In 41 core/resection pairs, the recognised trend to lower ER, PR and Ki67 score on resected material was confirmed. Concordance for ER, PR and Ki67 without changing biomarker status (e.g. ER+ to ER-) was 90, 74 and 80 % respectively. However, in 23 paired core samples (diagnostic core v on table core), Ki67 using a cut off of 13.25 % was concordant in 22/23 (96 %) and differences in ER and PR immunohistochemistry by Allred or Quickscore between the pairs did not impact hormone receptor status. IPA and GSA demonstrated substantial gene expression changes between paired cores at the mRNA level, including reduced expression of ER pathway analysis on the second core, despite the absence of drug intervention.

CONCLUSIONS

Sequential core biopsies of primary breast cancer (but not core versus resection) was consistent and is appropriate to assess the effects of drug therapy in vivo on ER, PR and Ki67 using immunohistochemistry. Conversely, studies utilising mRNA expression may require non-treatment controls to distinguish therapeutic from biopsy differences.

Combined Use of Unguided FNA and CNB Increases the Diagnostic Accuracy for Palpable Breast Lesions

BACKGROUND

Obtaining nonsurgical precise diagnosis of a palpable breast lesion is of paramount importance. Both core needle biopsy (CNB) and fine needle aspiration (FNA) are validated techniques used for this purpose. In this study, we compared the accuracy of both methods and explored whether combining both tests adds significant diagnostic value, and for the first time, we tested the concordance of tumor grading in parallel biopsies with reference to surgical excision (SE).

METHODS

Patients underwent concurrent unguided FNA and CNB followed by SE were retrospectively recruited. Chi-square was used to compare the accuracy of malignancy detection, and tumor grade agreement was calculated using kappa (k) statistical test with reference to SE findings.

RESULTS

All patients were females (n: 170). The median age was 45 years. Excluding 18 cases which had inadequate FNA, accuracy of FNA and CNB was 86.2% and 79.6%; respectively. Accuracy was 94.1% when we considered both tests together for any positive result. For tumor grading, the agreement was 91.6% for CNB and 98.8% for FNA.

CONCLUSION

Diagnostic strength was comparable for both FNA and CNB, slightly more favorable for the former. Combination of both tests significantly minimized missing cases as false negative. When available, it is worthy to grade malignant FNA samples. Diagn. Cytopathol. 2016;44:578-581. © 2016 Wiley Periodicals, Inc.

Meta-analysis of the concordance of histological grade of breast cancer between core needle biopsy and surgical excision specimen

BACKGROUND

With the increasing use of neoadjuvant chemotherapy and minimally invasive ablative therapy in breast cancer, pretreatment assessment of tumour grade on core needle biopsy (CNB) is increasingly needed. However, grading on CNB is possibly less accurate than grading based on the surgical excision specimen. A systematic review and meta-analysis of the literature was conducted to derive a reliable estimate of the agreement in tumour grading between CNB and subsequent surgical excision.

METHODS

Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) criteria, Embase, PubMed and the Cochrane Library were searched. Pooled proportions of agreement in grading between CNB and the excision specimen, Cohen's κ and percentages of overestimation and underestimation were calculated. Random-effects models were applied because of substantial heterogeneity, assessed by I² test. Determinants of the level of agreement in grading were explored with meta-regression.

RESULTS

Thirty-four articles were included in the systematic review (6029 patients) and 33 in the meta-analysis (4980 patients). Pooled agreement and κ were 71·1 (95 per cent c.i. 68·8 to 73·3) per cent and 0·54 (0·50 to 0·58) respectively. Underestimation and overestimation occurred in 19·1 (17·1 to 21·3) and 9·3 (7·7 to 11·4) per cent respectively. Meta-regression showed associations between agreement of histological type (positive association) and proportion of patients with oestrogen receptor-positive disease (negative association) and grade agreement.

CONCLUSION

Grading on CNB corresponds moderately with grading based on excision specimens, with underestimation in about one in five patients. Incorrect CNB tumour grading has limited clinical implications, as multiple factors influence decision-making for adjuvant systemic therapy.

Adjusting breast cancer patient prognosis with non-HER2-gene patterns on chromosome 17

Background

HER2 and TOP2A gene status are assessed for diagnostic and research purposes in breast cancer with fluorescence in situ hybridization (FISH). However, FISH probes do not target only the annotated gene, while chromosome 17 (chr17) is among the most unstable chromosomes in breast cancer. Here we asked whether the status of specifically targeted genes on chr17 might help in refining prognosis of early high-risk breast cancer patients.

Methods

Copy numbers (CN) for 14 genes on chr17, 4 of which were within and 10 outside the core HER2 amplicon (HER2- and non-HER2-genes, respectively) were assessed with qPCR in 485 paraffin-embedded tumor tissue samples from breast cancer patients treated with adjuvant chemotherapy in the frame of two randomized phase III trials.

Principal Findings

HER2-genes CN strongly correlated to each other (Spearman’s rho >0.6) and were concordant with FISH HER2 status (Kappa 0.6697 for ERBB2 CN). TOP2A CN were not concordant with TOP2A FISH status (Kappa 0.1154). CN hierarchical clustering revealed distinct patterns of gains, losses and complex alterations in HER2- and non-HER2-genes associated with IHC4 breast cancer subtypes. Upon multivariate analysis, non-HER2-gene gains independently predicted for shorter disease-free survival (DFS) and overall survival (OS) in patients with triple-negative cancer, as compared to luminal and HER2-positive tumors (interaction p = 0.007 for DFS and p = 0.011 for OS). Similarly, non-HER2-gene gains were associated with worse prognosis in patients who had undergone breast-conserving surgery as compared to modified radical mastectomy (p = 0.004 for both DFS and OS). Non-HER2-gene losses were unfavorable prognosticators in patients with 1–3 metastatic nodes, as compared to those with 4 or more nodes (p = 0.017 for DFS and p = 0.001 for OS).

Conclusions

TOP2A FISH and qPCR may not identify the same pathology on chr17q. Non-HER2 chr17 CN patterns may further predict outcome in breast cancer patients with known favorable and unfavorable prognosis.