Clinicopathological characteristics of oestrogen receptor negative, progesterone receptor positive breast cancers: re-evaluating subsets within this group

Safety analysis of therapeutic drugs for breast cancer patients and construction of a predictive model for serious adverse drug reactions

OBJECTIVES

To explore the characteristics of the occurrence of antineoplastic drug adverse reactions (ADRs) in breast cancer and to utilize a computerized tool to identify early warning indicators of potentially serious ADRs.

METHODS

We conducted descriptive statistical analyses of the demographic features, medication use characteristics, and clinical manifestations of suspected ADRs in ADR-exposed patients using data from the Shaanxi Provincial Adverse Drug Reaction Monitoring Center, China, from 2017 to 2021. Using disproportionality methods (reporting odds ratio, proportional reporting ratio, and comprehensive standard method), the relationship between drugs and ADRs was measured. Finally, a web-based clinical prediction model for serious ADRs based on binary logistic regression was developed to estimate individual event probabilities numerically.

RESULTS

We developed a new computer-mineable breast cancer-ADR system. In total, 1119 ADR reports were received between 2017 and 2021, with an increasing trend in the number. Antineoplastic medications of natural sources made up the greatest portion of the drug category (530, 38.10%) while targeted drugs' part increased with time. The medicine with the greatest number of ADR cases was docetaxel. Bone marrow failure was the most reported ADR. The disproportionality methods produced 19 signals of disproportionate reporting, two signals of disproportionate reporting were unknown ADRs. The occurrence of serious ADRs was shown to be substantially correlated with gender, platinum drugs, and blood and lymphatic system disorders. The clinical prediction model for serious ADRs had above-moderate discriminatory power (C-index was 0.775).

CONCLUSIONS

The number of ADRs to breast cancer antineoplastic drugs was constantly increasing, with docetaxel ranking first, with the majority of ADRs presenting as bone marrow suppression, nausea, and vomiting. Data mining identified 19 signals of disproportionate reporting.

Estrogen receptor-negative/progesterone receptor-positive breast cancer has distinct characteristics and pathologic complete response rate after neoadjuvant chemotherapy

PURPOSE

The status of hormone receptors (HR) is an independent factor affecting survival and chemotherapy sensitivity in breast cancer (BC) patients, with estrogen receptor (ER) and progesterone receptor (PR) having the most significant effects. The ER-/PR + phenotype has been controversial in BC, and experts will face many challenges in determining treatment strategies. Herein, we systematically analyzed the clinicopathological characteristics of the ER-/PR + phenotype in BC patients and the response to chemotherapy.

PATIENTS AND METHODS

We included two cohorts. The first cohort counted the relationship between clinicopathologic data and survival outcomes for 72,666 female patients in the Surveillance, Epidemiology, and End Results (SEER) database. The second cohort analyzed the relationship between clinicopathological data and pathologic complete response (pCR) rate in 879 patients at the Harbin Medical University Cancer Hospital. The classification data were compared by the chi-square test and Fister's exact test of the Logistic regression model, and predictor variables with P < 0.05 in the univariate analysis were included in the multivariate regression analysis. The Kaplan-Meier method evaluated breast cancer-specific survival (BCSS) and overall survival (OS) to investigate the relationship between different HR typing and survival and pCR.

RESULTS

In the two cohorts, 704 (0.9%) and 11 (1.3%) patients had the ER-/PR + phenotype, respectively. The clinicopathologic features of patients with the ER-/PR + phenotype are more similar to those of the ER-/PR- phenotype. The ER-/PR + phenotype is more common in younger and premenopausal women, and most ER-/PR + phenotypes exhibit higher histological grades. Survival analysis showed that there were significant differences in OS and BCSS among patients with different HR states (P < 0.001). The survival results of patients with the ER + /PR + phenotype were the best. The prognosis of the ER-/PR + phenotype was similar to that of the ER-/PR- phenotype. On the other hand, we found that HR status was also an independent predictor of post-NAC pCR rate in BC patients. The ER + /PR- and ER-/PR- phenotypes were more sensitive to chemotherapy than the ER + /PR + phenotypes.

CONCLUSION

HR status is the main factor affecting BC's survival outcome and pCR rate. Patients with the ER-/PR + phenotype possess more aggressive biological factors and can benefit significantly from chemotherapy. We need to pay more attention to this group and achieve individualized treatment, which will help us treat BC better and provide new targets and blueprints for our clinical treatment.

Impact of reactive changes on multigene testing: histopathologic analysis of low-grade breast cancers with high-risk 21-gene recurrence scores

PURPOSE

The 21-gene recurrence score (RS) assay predicts the recurrence risk and magnitude of chemotherapy benefit in patients with invasive breast cancer (BC). This study examined low-grade tumors yielding a high-risk RS and their outcomes.Kindly check the edit made in the article titleOk  METHODS: We compared patients with grade 1 BC and a high-risk RS to those with low-risk RS. Histologic sections were reviewed and features reported to elevate the RS were noted, mainly biopsy cavity and reactive stromal changes (BXC).

RESULTS

A total of 54 patients had high-risk RS (median RS of 28, range 26-36). On review, BXC were seen in all cases. Thirty BCs in this group also had low to negative PR. Treatment regimens included: chemoendocrine therapy (63%), endocrine therapy alone (31%) and no adjuvant therapy (6%). There were no additional breast cancer events over a median follow-up of 54.0 months (range 6.2 to 145.3). A total of 108 patients had low-risk RS (median RS of 7, range 0-9). BXC were seen in 47% of cases and none were PR negative. One patient had a recurrence at 64.8 months while the rest had no additional events over a median of 68.1 months (2.4 to 100).

CONCLUSION

We provide further evidence that reactive stromal changes and/or low-PR scores enhance the elevation of the RS. A high-RS result in low grade, PR-positive BC may not reflect actual risk and any suspected discrepancies should be discussed with the management teams. Multigene testing results should be interpreted after correlation with pathologic findings to optimize patient care.

Clinicopathological characteristics and prognostic analysis of breast cancer with a hormone receptor status of ER(-)/PR(+)

Background

It is unknown whether ER(-)/PR(+) breast cancer is an independent breast cancer subtype, how it differs from other subtypes, and what its significance is regarding treatment and prognosis. This study compared ER(-)/PR(+) breast cancer with other subtypes to better understand the biological characteristics and prognosis of ER(-)/PR(+) breast cancer, to guide clinical treatment and establish a theoretical foundation.

Methods

We retrospectively analyzed data for patients diagnosed with breast cancer in the Surveillance, Epidemiology, and End Results (SEER) database. The clinicopathological characteristics of ER(-)/PR(+) breast cancer, including age, tumor size, lymph node status, HER-2 status, pathological type and histological grade, were compared with other types of breast cancer. A risk scoring system was developed based on independent risk factors influencing prognosis to predict the patient's prognosis, and a nomogram model was created to predict the patient's survival rate. Receiver operating characteristic curve (ROC) and calibration curve was used to evaluate the predictive performance of the nomogram.

Results

The rates of T3-4, lymph node positivity, HER-2 positivity, infiltrating non-special pathological type, and G3 were significantly higher in ER(-)/PR(+) than in ER(+)/PR(+) cancer (p <0.001). ER(-)/PR(+) was similar to biological activity of ER(-)/PR(-) type. ER(-)/PR(+)/HER-2(+) patients had a better survival prognosis than ER(-)/PR(+) HER-2(-) patients (p<0.05). The prognosis of ER-/PR+ breast cancer was significantly associated with age, HER-2 status, and T stage.

Conclusion

ER(-)/PR(+) breast cancer is more similar to ER(-)/PR(-) breast cancer than other breast cancer subtypes, with an early age of onset, a high proportion of infiltrating non-special types, a high histological grade, and a high HER-2 positivity rate. Whether HER-2 positivity can improve the prognosis of ER(-)/PR(+)breast cancer is worth further discussion. The risk scoring system we developed can effectively distinguish between high-risk and low-risk patients. The nomogram we created had a concordance index of 0.736, and the calibration curve showed good agreement between the predicted and observed outcomes.

A controversial ER negative PR positive molecular subtype of breast carcinoma-Report of two cases

ER-/PR+ is a controversial subtype and is not formally recognised as molecular subtype of breast carcinoma. Few studies concluded that this subtype does not exist and is due to technical errors, however, in contrast others consider it to be distinct entity with different response to therapy and clinical outcome. It is also essential to know whether this subtype shows any distinct histomorphological features or prognosis.Therefore, the present two cases of controversial subtype ER-/PR+ breast cancer is being reported with both the cases showing neuroendocrinal differentiation.

Single progesterone receptor-positive phenotype has the similar clinicopathological features and outcome as triple-negative subtype in metastatic breast cancer

Objective

The same clinicopathological features and prognosis have been reported between single progesterone receptor-positive (sPR-positive) and triple-negative phenotype in early-stage breast cancer, but such similarity has not been studied in metastatic breast cancer (MBC). Therefore, the purpose of this study was to estimate the difference between sPR-positive phenotype and other phenotypes in MBC.

Methods

Patients with HER-2-negative MBC were selected from the Surveillance, Epidemiology and End Results database. Pearson's χ2 test was used to compare the difference of clinicopathologic factors between sPR-positive phenotype and other phenotypes. Univariate and multivariate analyses were performed to evaluate the effects of hormone receptor (HoR) phenotypes and other clinicopathologic factors on the cancer-specific survival (CSS) and overall survival (OS).

Results

Overall, 10877 patients including 7060 patients (64.9%) with double HoR-positive (dHoR-positive), 1533 patients (14.1%) with single estrogen receptor-positive (sER-positive), 126 patients (1.2%) with sPR-positive and 2158 patients (19.8%) with double HoR-negative (dHoR-negative) were analyzed. The patients with sPR-positive or dHoR-negative were more likely to be younger, higher grade and tumor stage, visceral and brain metastasis than ER-positive phenotypes (P<0.001). MBC with sPR-positive had the similar CSS (HR: 1.135, 95%CI: 0.909-1.417, P=2.623) and OS (HR: 1.141, 95%CI: 0.921-1.413, P=0.229) as dHoR-negative, but worse outcome than ER-positive phenotypes. Chemotherapy significantly improved the survival for MBC, especially for sPR-positive MBC (CSS, HR: 0.39, 95%CI: 0.213-0.714, P=0.002; OS, HR: 0.366, 95%CI: 0.203-0.662, P=0.001).

Conclusions

Patients with sPR-positive and triple-negative have similar biological behavior and prognosis in MBC. Chemotherapy may be a preferred recommendation for MBC with sPR-positive.

Prospect of exosomal circular RNAs in breast Cancer: presents and future

Implementing precision oncology for breast cancer (BC) is a critical method for improving patient outcomes, which relies on the use of reliable biomarkers to be effective and safe. exosomes represent a potential alternative for the diagnosis and therapy of BC, As a "liquid biopsy" and a novel source for biomarkers. Exosomes are nanoscale phospholipid bilayer vesicles released by most cells that contain a large payload of various RNA species that can alter recipient cell activity. Circular RNAs (circRNAs) were recently revealed as a looping subclass of competing endogenous noncoding RNAs (ceRNAs) capable of microRNA sponging to regulate gene expression. They provide critical regulatory functions in carcinogenesis, proliferation, invasion, metastasis, and treatment resistance, as well as cancer prognostic. However, there is still a major gap in our understanding of the role of circRNA in the advancement of BC. CircRNAs are abundant in exosomes, according to various studies, and exosomal circRNAs (exo-circRNAs) play a significant role in cancer biology. Exo-circRNAs can be picked up by nearby or distant cells, affecting many features of the target cells' pathophysiological states, thus boosting cell communication and tumor spread. In this review, we have briefly summarized the major properties and functions of exosomes. Then, we have focused on exo-circRNAs, discussing their potential roles in both driving and inhibiting BC, as well as for cancer diagnosis, prognosis, and monitoring.

Assessment of Predictive Biomarkers in Breast Cancer: Challenges and Updates

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.

The Prognosis and Predictive Value of Estrogen Negative/Progesterone Positive (ER−/PR+) Phenotype: Experience of 1159 Primary Breast Cancer from a Single Institute

Breast cancer is a serious worldwide public health problem and is currently the most common cancer overall. Its endocrine therapy is related to the expression of the steroid hormones, estrogen receptor (ER), and progesterone receptor (PR). Breast cancers can be presented under multiple profiles of steroid hormones: ER(−)/PR(+), ER(+)/PR(−), double-positive/negative ER, and PR. 2–8% of all breast cancers express only PR (ER−/PR+) which is an abnormal phenotype, with less known about their behaviors and outcomes. Our study was performed on a large and well-characterized database of primary breast cancer from 2012 to 2019, up to 1159 cases. These cases were divided according to ER and PR expression, as we put all of our focus on ER-negative/PR-positive group, more specifically ER−/PR+/HER2+ and ER−/PR+/HER2− gene expressions, to highlight their features and find a pattern that links HR (hormone receptors) profiles and breast cancer subtypes. Out of the informative cases, 94 patients (8%) had ER−/PR+ breast cancers, while 676 (58.4%) had ER+/PR+, 88 (7.6%) had ER+/PR−, and 164 (14.2%) had ER−/PR− tumors. The ER−/PR+ group was statistically correlated with a high risk of recurrence and death in midway between the double-negative and double-positive HR. According to HER2 status, a low DFS was observed in patients ER−/PR+/HER2−, which is closer to the DFS of TNBC cases but worse than ER+/PR any. On the other side, the ER−/PR+/HER2+ showed also a poorer DFS closer to the HER2+ subgroup in between TNBC and ER+/PR any. The clinicopathological features of the ER−/PR+/HER2− and ER−/PR+ HER2+ have distinguished the patients into two groups with a difference in some clinicopathological characteristics: both groups had closer OS estimation, which was worse than ER−/PR any and better than TNBC and HER2. The ER−/PR+/HER2− seems to increase the risk of recurrence than ER−/PR+/HER2+ when compared to ER+/PR any. On the other hand, the ER−/PR+/HER2+ seems to increase the risk of death more than ER−/PR+/HER2− in comparison with ER+/PR any. Our results support that ER−/PR+ tumors really exist and are rare and clinically and biologically distinct subtypes of breast cancer. In addition, our analysis, which was based on dividing the groups according to HER2 expression, has revealed the existence of two distinct groups; this gave the ER−/PR+ subgroup a heterogeneity characterization. Moreover, this breast cancer subtype should not be treated as a luminal tumor but rather according to the HER2 expression status.

Oral Contraceptive Use and Breast Cancer Risk According to Molecular Subtypes Status: A Systematic Review and Meta-Analysis of Case-Control Studies

We conducted a systematic review and meta-analysis to investigate the effect of oral contraceptives (OCs) on risk of breast cancer (BrCa) by status of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). We searched the MEDLINE (PubMed), Embase and the Cochrane Library database and bibliographies of pertinent articles published up to 2020. Therein, we identified nineteen eligible case-control studies which provided data by breast cancer subtypes: ER-positive (ER+), ER-negative (ER−), HER2-positive (HER2+) and Triplet-negative (TN). Summary risk estimates (pooled OR [pOR]) and 95% confidence intervals (CIs) were calculated using fixed/random effects models. The summary meta-analysis showed that over-use of OCs led to significant increased risk of TNBrCa (OR = 1.37, 95% CI; 1.13 to 1.67, p = 0.002), as well as of ER−BrCa (OR = 1.20, 95% CI: 1.03 to 1.40, p = 0.019). There was also a significant reduction in the risk of ER+BrCa (OR = O.92, 95% CI: 0.86 to 0.99, p = 0.026,) and a slight reduction in the risk of HER2+BrCa (OR = 0.95, 95% CI; 0.79 to 1.14, p = 0.561) after taking OCs. Meta-analysis indicated that OC use has different impacts on risk of breast cancer subtypes defined by receptor status. The identified differences between individual subtypes of breast cancer may reflect different mechanisms of carcinogenesis.

High expression of progesterone receptor may be an adverse prognostic factor in oestrogen receptor-negative/progesterone receptor-positive breast cancer: results of comprehensive re-evaluation of multi-institutional case series

Oestrogen receptor (ER)-negative (-) progesterone receptor (PgR)-positive (+) is the least common combination of steroid receptor expression observed in breast cancer. There are many controversies regarding the actual existence of ER-/PgR+ phenotype. In the current study, we aimed to perform comprehensive immunohistochemical re-evaluation of ER-/PgR+ breast cancers from multiple institutions. A total of 135 cases of ER-/PgR+ breast cancer were collected from 11 institutions from the period 2006-2020 and subsequently stained with three clinically validated anti-ER antibody clones: SP1 (Roche), 1D5 (Dako), and EP1 (Dako), and two anti-PgR antibody clones: 636 (Dako), and 1E2 (Roche). Clinicopathological characteristics of confirmed and re-categorised cases were analysed. Seventy-six cases retained the original ER-/PgR+ phenotype, including 21 HER2+ and 55 HER2- tumours. Forty-seven cases were ER+ with at least one anti-ER antibody, and 12 cases were re-categorised as double-negatives across all anti-ER and anti-PgR antibodies. No significant differences in survival were observed between groups in the HER2+ category. In the HER2- cohort, confirmed ER-/PgR+, ER+ tumours with discrepant ER staining, and triple negatives had inferior overall survival compared to concordant ER+ cases. Progesterone receptor expression in >20% of cells was identified as an adverse prognostic factor in ER-/PgR+/HER2- breast cancer in a multivariable model adjusted by stage (HR 5.0, 95% CI 1.3-19.2, p=0.019). We performed one of the largest validation studies so far on ER-/PgR+ breast cancer and confirmed the existence of this subgroup. Moreover, we identified high PgR expression as an adverse prognostic factor.

Is oestrogen receptor-negative/progesterone receptor-positive (ER-/PR+) a real pathological entity?

Background

The existence of oestrogen receptor-negative (ER−)/progesterone receptor-positive (PR+) breast cancer continues to be an area of controversy amongst oncologists and pathologists.

Methods

To re-evaluate breast cancers originally classified as ER−/PR+ via Oncotype DX® assay and compare molecular phenotype with Recurrence Score® (RS) result, clinicopathologic features and clinical outcomes were retrospectively obtained from electronic health records between January 1998 and June 2005. Archived formalin-fixed, paraffin-embedded (FFPE) tumour specimens were tested for the expression of ER, PR and human-epidermal-growth-factor-2. The number of positive ER−/PR+ samples confirmed by transcriptional analysis was the primary outcome of interest with event-free and overall survival as secondary outcomes. Biopsies from 26 patients underwent Oncotype DX testing and analysis.

Results

Approximately 60% were middle-aged (40–50 years old) women, and 84.6% had invasive ductal carcinoma. Based on the Oncotype DX assay, approximately 65% (N = 17) had ER+/PR+ status; 23% (N = 6) had ER−/PR− status; and 12% had a single hormone positive receptor (1 ER–/PR+, 2 ER+/PR–) status. Almost one-quarter of patients were stratified into the low-RS (<18) or intermediate-RS (18–30) results, and half of the patients had a high-RS (>30) result.

Conclusion

Our findings suggest the ER−/PR+ subtype is not a reproducible entity and emphasises the value of retesting this subtype via molecular methods for appropriate treatment selection and patient outcomes. Multigene assay analysis may serve as a second-line or confirming tool for clinical determination of ER/PR phenotype in breast cancer patients for targeted therapies.

Clinical features of patients with HER2-positive breast cancer and development of a nomogram for predicting survival

Background

Different estrogen receptor (ER) and progesterone receptor (PR) expression patterns have important biological and therapeutic implications in patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer. However, little is known about hormone receptor (HR)-positive and triple-positive subtypes, making therapy selection and survival prognosis difficult. This study investigated the clinical characteristics and nomogram-predicted survival of patients with HER2-positive breast cancer.

Materials and methods

Data on patients with HER2-positive breast cancer were retrieved from the Surveillance, Epidemiology, and End Results database. Comparisons were carried out between single HR-positive and double HR-positive/double HR-negative subtypes. A nomogram-based model of predicted outcomes was developed.

Results

This cohort study included 34 819 patients with breast cancer (34 606 women and 213 men). Single HR-positive and double HR-positive/double HR-negative subtypes showed distinct clinicopathological characteristics. Multivariable Cox regression analysis showed that patients with ER-positive/PR-negative/HER2-positive [hazard ratio (HR) = 1.24; 95% confidence interval (CI): 1.14-1.39], ER-negative/PR-positive/HER2-positive (HR = 1.56; 95% CI: 1.23-1.97), and ER-negative/PR-negative/HER2-positive (HR = 1.56; 95% CI: 1.43-1.70) subtypes had worse breast cancer-specific survival than patients with the triple-positive subtype. Thirteen clinical parameters were included as prognostic factors in the nomogram: age, sex, race, grade, histology type, bone, brain, liver, and lung metastasis, TNM (tumor–node–metastasis) staging, and molecular subtype. The C-index was 0.853 (95% CI: 0.845-0.861). Calibration plots indicated that the nomogram-predicted survival was consistent with the recorded 3-year and 5-year prognoses.

Conclusions

Significant differences in survival rates were observed between single HR-positive and double HR-positive/double HR-negative subtypes. A nomogram accurately predicted survival. Different treatment strategies may be required for HER2-positive patients with single HR-positive and double HR-positive tumors to ensure optimal treatment and benefits.

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Significant differences in survival were observed in single HR-positive and double HR-positive/double HR-negative subtypes.

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A nomogram based on molecular subtypes of HER2-positive breast cancer accurately predicted breast cancer-specific survival.

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Different treatment strategies may be required for HER2-positive breast cancer to ensure optimal treatment and benefits.

The Prognosis of Single Hormone Receptor-Positive Breast Cancer Stratified by HER2 Status

Single estrogen receptor (ER)+ and progesterone receptor (PR)+ tumors account for about10% of all breast cancers. However, the prognosis of these single hormone receptor-positive (HR+) tumor remains unclear. We aimed to investigate the characteristics of single HR+ breast tumors according to HER2 status in order to improve the treatment of patients with single HR+. Patients from the SEER program (2010-2016) were divided into ER+PR-, ER-PR+, ER+PR+ and ER-PR- molecular subtypes stratified by HER2 status. Overall survival (OS) and breast cancer-specific survival (BCSS) were compared by Kaplan–Meier curves after propensity score matching (PSM). A total of 203,406 patients were enrolled. Single ER+ and PR+ tumors account for 11.9% of the total population. For HER2- subtype, patients with ER+PR- (n = 16906 pairs) and ER-PR+ (n = 1395 pairs) had worse prognoses than those with ER+PR+ with hazard ratio (HR) and 95% confidence interval (CI) of 1.52 (1.41-1.64) and 2.25 (1.76-2.88) for OS; and 1.94 (1.76-2.14) and 2.57 (1.94-3.40) for BCSS, respectively; ER+PR- showed a better prognosis than ER-PR+ (n = 1394 pairs) and ER-PR- (n = 9626 pairs) with HR (95% CI) of 1.32 (1.06-1.65) and 1.44 (1.33-1.55) for OS, and 1.32 (1.03-1.69) and 1.46 (1.34-1.60) for BCSS, respectively; ER-PR+ had a similar prognosis relative to ER-PR- (n = 1395 pairs) after PSM. For HER2+ subtype, patients with ER-PR+, ER+PR-, and ER-PR- had similar OS and BCSS; ER+PR+ showed a similar prognosis compare with ER-PR+ (n = 535 pairs), but had better OS and BCSS than ER+PR- (n = 5376 pairs) and ER-PR- (n = 8143 pairs) after PSM. In addition, ER+PR+HER2+ showed similar OS and better BCSS compared with ER+PR+HER2- after PSM. In conclusion, single PR+ patients experienced poorer prognoses than single ER+ patients, and may be treated as ER-PR- patients in HER2- subtype. In HER2+ patients, both single ER+ and single PR+ cases showed similar prognoses compared with ER-PR- cases, and may be treated as ER-PR- patients.

Single Hormone Receptor-Positive Metaplastic Breast Cancer: Similar Outcome as Triple-Negative Subtype

Background

Metaplastic breast cancer (MBC) is a rare and aggressive subtype of the breast. To understand the characteristics and prognosis of single hormone receptor-positive (HR+) MBC (estrogen receptor-positive [ER+]/progesterone receptor-negative [PR-] and ER-/PR+), we compared these tumors to double HR+ tumors as well as HR- tumors.

Patients and Methods

The Surveillance, Epidemiology, and End Results database was used to analyze MBC between 1975 and 2016. The effect of HR status was evaluated using a multivariate Cox regression model.

Results

We included 3369 patients with a median follow-up time of 42 months (range 0-322 months). In this study, 280 (8.3%) cases were double HR+ tumors, 2597 (77.1%) were double HR- tumors, and 492 (14.6%) cases were single HR+ tumors, of which 159 (4.7%) cases were ER-/PR+ tumors and 333 (9.9%) were ER+/PR- tumors. On multivariate Cox analysis, the prognosis was related to age, race/ethnicity, tumor grade, TNM stage, and surgery. HR status remained no impact on breast cancer-specific survival (BCSS). In the Kaplan-Meier curve, HR status was not associated with better BCSS or overall survival (OS). In patients without HER2 overexpression, the BCSS and OS of ER+/PR- and ER-/PR+ tumors were not significantly different from that of ER-/PR- and ER+/PR+ tumors. The difference remains no significant in patients with HER2 overexpression.

Conclusions

In comparison with both ER-/PR- and ER+/PR+ tumors, we have identified clinically and biologically distinct features of single HR+ tumors. In patients with or without HER2 overexpression, the prognosis of single HR+ tumors was similar to ER-/PR- and ER+/PR+ tumors.

Phenotypic discordance between primary and metastatic breast cancer in the large-scale real-life multicenter French ESME cohort

Expression of hormone receptor (HR) for estrogens (ER) and progesterone (PR) and HER2 remains the cornerstone to define the therapeutic strategy for breast cancer patients. We aimed to compare phenotypic profiles between matched primary and metastatic breast cancer (MBC) in the ESME database, a National real-life multicenter cohort of MBC patients. Patients with results available on both primary tumour and metastatic disease within 6 months of MBC diagnosis and before any tumour progression were eligible for the main analysis. Among the 16,703 patients included in the database, 1677 (10.0%) had available biopsy results at MBC diagnosis and on matched primary tumour. The change rate of either HR or HER2 was 27.0%. Global HR status changed (from positive = either ER or PR positive, to negative = both negative; and reverse) in 14.2% of the cases (expression loss in 72.5% and gain in 27.5%). HER2 status changed in 7.8% (amplification loss in 45.2%). The discordance rate appeared similar across different biopsy sites. Metastasis to bone, HER2+ and RH+/HER2- subtypes and previous adjuvant endocrine therapy, but not relapse interval were associated with an HR discordance in multivariable analysis. Loss of HR status was significantly associated with a risk of death (HR adjusted = 1.51, p = 0.002) while gain of HR and HER2 discordance was not. In conclusion, discordance of HR and HER2 expression between primary and metastatic breast cancer cannot be neglected. In addition, HR loss is associated with worse survival. Sampling metastatic sites is essential for treatment adjustment.

ER-/PR+ breast cancer: A distinct entity, which is morphologically and molecularly close to triple-negative breast cancer

Determining the status of steroid hormone receptors [oestrogen (ER) and progesterone receptors (PR)] is a crucial part of the breast cancer workup. Thereby, breast cancers can be classified into four subtypes. However, the existence of ER-/PR+ tumours, often reported to be ill-classified due to technical errors, remains controversial. In order to address this controversy, we reviewed the hormone receptor status of 49 breast tumours previously classified as ER-/PR+ by immunohistochemistry, and compared clinical, pathological and molecular characteristics of confirmed ER-/PR+ tumours with those of ER+ and triple-negative tumours. We unequivocally confirmed the ER-/PR+ status in 27 of 49 tumours (0.3% of all breast cancers diagnosed in our institution between 2000 and 2014). We found that ER-/PR+ were morphologically and histologically similar to triple-negative tumours, but very distinct from ER+ tumours, with more aggressive phenotypes and more frequent basal marker expression than the latter. On the molecular level, RNA sequencing revealed different gene expression profiles between the three groups. Of particular interest, several genes controlled by the suppressor of zest 12 (SUZ12) were upregulated in ER-/PR+ tumours. Overall, our results confirm that ER-/PR+ breast cancers are an extremely rare but 'real' tumour subtype that requires careful diagnosis and has distinct features warranting different responsiveness to therapies and different clinical outcomes. Studies on larger cohorts are needed to further characterise these tumours. The likely involvement of SUZ12 in their biology is an interesting finding which may - in a long run - give rise to the development of new therapeutic alternatives.

Epithelial-mesenchymal transition and cancer stem cell interactions in breast phyllodes tumours: immunohistochemical evaluation of EZH2, EZR, HMGA2, CD24 and CD44 in correlation with outcome analysis

AIM

Phyllodes tumours (PTs) categorised as benign, borderline and malignant, account for 1% of all breast tumours. Histological assessment does not always predict tumour behaviour, hindering determination of the clinical course and management.Epithelial-mesenchymal transition (EMT) is an important process during embryogenesis. Dysregulation of EMT causes loss of cell polarity, decreased intercellular adhesion, increased motility and invasiveness, promoting tumour progression. Similarly, cancer stem cells (CSCs) promote tumour growth, resistance and recurrence. The aim of this study is to evaluate expression of CSC markers; enhancer of zeste homolog 2 (EZH2), CD24 and CD44 and EMT associated proteins; ezrin (EZR) and high-mobility group AT-hook 2 (HMGA2) in PTs.

METHOD

Uing tissue microarray sections, immunohistochemistry was performed on 360 PTs. Epithelial and stromal expressions of EZH2, EZR, HMGA2, CD24 and CD44 were evaluated to assess their impact on disease progression and behaviour in correlation with clinicopathological parameters.

RESULTS

Stromal expression of EZH2, EZR and HMGA2 was observed in 73 (20.3%), 53 (14.7%) and 28 (7.8%) of tumours, epithelial expression in 121 (35.9%), 3 (0.8%) and 351 (97.5%) tumours, respectively. CD24 and CD44 staining was absent in both components.

CONCLUSION

Expression of biomarkers correlated significantly with aggressive tumour traits such as stromal hypercellularity, atypia, mitoses and permeative tumour borders.Stromal expression of EZH2 and EZR shortened disease-free survival and overall survival; HMGA2 expression did not alter patient survival. EZH2 and EZR may thus be useful in predicting PT behaviour.

Negative estrogen receptors and positive progesterone receptors breast cancers

CONTEXT

Hormone receptors (estrogen receptor ER and progesterone receptor PR) are prognostic and predictive factors of outcome for invasive breast cancer. Some tumors only express one of these hormone receptors (ER or PR). ER negative/PR positive breast cancer is a rare subtype (1-4 %) and its existence still controversial. The aim of this study was to evaluate characteristics of this group of tumors.

METHODS

We collected data of all consecutive patients managed in our institution for invasive breast cancer between the 1st January 2007 and 31 December 2013. The aim of the study was to compare data of patients with ER-/PR+tumors with the three other subgroups.

RESULTS

Of the 2071 patients included during the study period, 1.2 % were ER-/PR+. These patients were younger than those with the two ER+groups (p<0.0001). The ER-/PR+tumors differed from the ER+groups for several histological prognostic factors: greater histological size (p=0.0004), higher histological grade, more HER2 overexpression/amplification, more association with ductal carcinoma in situ, more lymphovascular invasion, more nodal metastasis (p<0.0001). Chemotherapy was more often used as an adjuvant treatment in addition of endocrine therapy. Survival was equivalent for patients with ER-/PR+tumors and ER+tumors and significantly higher than patients with ER-/PR- tumors (p<0.0001).

CONCLUSION

Women with ER-/PR+breast cancer have worse prognostic factors than women with ER+cancers but have better overall survival than women with ER-/PR- tumors. We may think that the more frequent association of chemotherapy and endocrine therapy is responsible for this better outcome.

Estrogen and Progesterone Receptor Testing in Breast Cancer: American Society of Clinical Oncology/College of American Pathologists Guideline Update

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 .

Estrogen and Progesterone Receptor Testing in Breast Cancer: ASCO/CAP Guideline Update

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.

Clinical Characteristics and Outcomes of Single Versus Double Hormone Receptor-Positive Breast Cancer in 2 Large Databases

PURPOSE

To identify biologic and outcome differences between double hormone receptor (HR)-positive (dHR⁺, estrogen receptor (ER)⁺/progesterone receptor [PgR⁺]) and single HR-positive (sHR⁺, either ER⁺/PgR^- or ER^-/PgR⁺) breast cancer; and to explore whether hormone therapy (HT) response in HER2-negative breast cancer correlates with HR status.

PATIENTS AND METHODS

This retrospective study was conducted by using 2 large breast cancer databases: the Surveillance, Epidemiology, and End Results (SEER) database and the Molecular Taxonomy of Breast Cancer International Consortium (METABRIC) clinical data set. Cox regression analysis was used to estimate overall survival (OS) and breast cancer-specific survival (BCSS) among sHR⁺ and dHR⁺ patients.

RESULTS

In the SEER database, dHR⁺ patients had significantly longer OS and BCSS than ER⁺/PgR^- patients in short-term follow-up (OS: hazard ratio = 0.620; 95% confidence interval [CI], 0.590, 0.652; P < .001; BCSS: hazard ratio = 0.493; 95% CI, 0.462, 0.526; P < .001). Meanwhile, ER^-/PgR⁺ patients had younger age, larger tumor size, and higher disease grade than dHR⁺ and ER⁺/PgR^- patients. In patients who received HT, dHR⁺ patients had a more favorable OS than ER⁺/PgR^- patients (hazard ratio = 0.789; 95% CI, 0.635, 0.982; P = .034), and ER^-/PgR⁺ patients had a worse OS than ER⁺/PgR^- patients at 10 years' follow-up (hazard ratio = 7.991; 95% CI, 1.053, 60.644; P = .044). However, these groups had similar outcomes over longer periods.

CONCLUSION

In HER2-negative breast cancer, sHR⁺ patients are associated with relatively worse characteristics and worse short-term outcomes than dHR⁺ patients. Additionally, the outcome of patients receiving HT may differ according to the HR status. However, further studies are needed to confirm these conclusions.

Single hormone receptor-positive breast cancer patients experienced poor survival outcomes: a systematic review and meta-analysis

BACKGROUND

The prognostic and clinical significance of single hormone receptor expression in breast cancer has not been clearly established. The goal of this study was to conduct a meta-analysis to compare the clinical outcomes of patients with ER+PR- tumours and ER-PR+ tumours to those of patients with ER+PR+ tumours.

METHODS

A systematic review of the literature was conducted to identify studies that compared the clinical outcome of patients with ER+PR- tumours or ER-PR+ tumours with those of patients with ER+PR+ tumours. A total of 18 studies met the inclusion criteria and included 217,485 women. Standard methods for meta-analysis were used, including fixed-effect models.

RESULTS

Patients with ER+PR- tumours or ER-PR+ tumours had significantly worse DFS (HR 1.60, 95% CI 1.44-1.77 and HR 2.27, 95% CI 1.67-3.09), BCSS (HR 1.43, 95% CI 1.33-1.53 and HR 1.82, 95% CI 1.68-1.98) and OS (HR 1.38, 95% CI 1.28-1.47 and HR 1.48, 95% CI 1.17-1.89) than those of patients with ER+PR+ tumours. In subgroup analyses, patients who had ER+PR- tumours experienced a higher risk of recurrence than patients with ER+PR+ tumours in the HER2- (HR 1.57, 95% CI 1.32-1.87), LN - (HR 2.07, 95% CI 1.44-2.86) and endocrine therapy (HR 1.65, 95% CI 1.45-1.89) subgroup. Patients who had HER2- and ER-PR+ tumours had an increased risk of recurrence compared with patients who had HER2- and ER+PR+ tumours (HR 3.10, 95% CI 1.92-5.10).

CONCLUSIONS

Among patients with hormone receptor-positive breast cancer, patients with either ER+PR- tumours or ER-PR+ tumours have a higher risk of recurrence and a shorter survival time than those with ER+PR+ tumours. Patients with both types of breast cancer need additional or better treatments.

The predictive value of the prognostic staging system in the 8th edition of the American Joint Committee on Cancer for triple-negative breast cancer: a SEER population-based analysis

Aim: To examine the stage changes and survival differences among triple-negative breast cancer (TNBC) patients based on the prognostic staging system. Methods: We used the SEER database to identify eligible patients with TNBC diagnosed between 2010 and 2014. Kaplan–Meier curves were drawn for comparison. The primary end point was breast cancer-specific survival. Results: The median follow-up time was 26 months for 19,608 patients. The stages of all TNBC patients increased or remained unchanged during rearrangement from anatomic staging to prognostic staging. Stage IIA, IIIA and IIIC comprised the majority of patients. Several patients did not have prognostic staging. Stage IIIC incorporated six substages that contributed to high heterogeneity. Overall, the Kaplan–Meier curves still showed the favorable differentiation among stages and substages, with the exception of stage IIB and substage IIIA (T2N0, grade 2–3) patients. Conclusion: The prognostic information for breast cancer patients provided by the novel prognostic staging system may be less accurate for TNBC patients in our independent analysis. Moreover, stage IIB and substage IIIA (T2N0, grade 2–3) should possibly undergo further evaluation.

Multifocal/Multicentric Ipsilateral Invasive Breast Carcinomas with Similar Histology: Is Multigene Testing of All Individual Foci Necessary?

BACKGROUND

Multiple synchronous ipsilateral invasive breast carcinomas (BCs) with similar histology usually have concordant receptor status. It is unknown whether individual foci with similar histology also share molecular and biological similarities or are heterogenous. This study examined the concordance of the 21-gene recurrence score (RS) in multiple synchronous morphologically similar ipsilateral BCs.

PATIENTS AND METHODS

We identified patients with multiple ipsilateral BCs and available RS treated at our institution from 1/2014 to 6/2018. BCs were divided into three groups based on RS: (1) RS in same risk category, (2) RS in different risk categories but within 2-unit difference (e.g., RS 17 and RS 19), and (3) RS in different risk categories and a change of > 2 units. BCs in groups 1 and 2 were considered as concordant (no significant clinical impact) and BCs in group 3 as discordant (variation affects management).

RESULTS

A total of 53 patients met the study criteria. RS was concordant in 46 (87%) cases. Seven (13%) cases were discordant (group 3). Of these, three (43%, 3/7) had biopsy cavity changes (BXC) adjacent to the BC with highest RS. In two cases the focus with higher RS had a lower percentage of progesterone receptor-positive tumor cells. In two cases, extensive ductal carcinoma in situ was associated with the BC focus with lower RS.

CONCLUSIONS

Morphologically similar multifocal ipsilateral BCs have concordant RS in 87% (46/53) of cases. Our results suggest that, in cases of morphologically similar multifocal BCs, testing of a single focus provides accurate prognostic and predictive information.

Oestrogen receptor-negative/progesterone receptor-positive phenotype of invasive breast carcinoma in Japan: re-evaluated using immunohistochemical staining

Background

The existence of progesterone receptor (PgR) expression in oestrogen receptor (ER)-negative breast carcinoma is controversial. Here, we re-evaluated ER-negative/PgR-positive (ER−/PgR+) carcinoma cases by immunohistochemical staining (IHC).

Materials and methods

We selected patients who underwent surgery for primary breast carcinoma from our databases at Dokkyo Medical University Hospital and Kameda General Hospital. Among the 9844 patients, the largest series in Japan, 27 (0.3%) were initially diagnosed as ER−/PgR+ breast carcinomas and we re-evaluated by IHC.

Results

The re-evaluated IHC showed that of the 27 patients with the initial results of ER−/PgR+, 12 were ER+/PgR+, 8 were ER−/PgR−, and 7 were ER−/PgR+. ER was negative in 12 of 27 patients (44.4%), and PgR was positive in 8 of 27 patients (29.6%). In our seven re-evaluated and confirmed as ER−/PgR+ cases, the staining proportions of tumor cells were 0% in ER and 1–69% (average 15.8%) in PgR. The average staining proportion of PgR in the re-evaluated ER−/PgR+ phenotype was lower than the initial diagnosis. Histological grading was as follows: grade I, one case; grade II, two cases; grade III, four cases. There were two lymph-node-positive cases.

Conclusions

The ER−/PgR+ phenotype was confirmed after re-evaluation of ER and PgR assessment by a different pathologist. We recommend that pathologists discuss with clinicians, or re-test and re-evaluate ER/PgR expression, particularly in low-grade carcinoma and with a high staining proportion of PgR in the ER−/PgR+ phenotype.

Circulating anti-Müllerian hormone and breast cancer risk: A study in ten prospective cohorts

A strong positive association has been observed between circulating anti-Müllerian hormone (AMH), a biomarker of ovarian reserve, and breast cancer risk in three prospective studies. Confirming this association is important because of the paucity of biomarkers of breast cancer risk in premenopausal women. We conducted a consortium study including ten prospective cohorts that had collected blood from premenopausal women. A nested case-control design was implemented within each cohort. A total of 2,835 invasive (80%) and in situ (20%) breast cancer cases were individually matched to controls (n = 3,122) on age at blood donation. AMH was measured using a high sensitivity enzyme-linked immunoabsorbent assay. Conditional logistic regression was applied to the aggregated dataset. There was a statistically significant trend of increasing breast cancer risk with increasing AMH concentration (ptrend across quartiles <0.0001) after adjusting for breast cancer risk factors. The odds ratio (OR) for breast cancer in the top vs. bottom quartile of AMH was 1.60 (95% CI = 1.31-1.94). Though the test for interaction was not statistically significant (pinteraction  = 0.15), the trend was statistically significant only for tumors positive for both estrogen receptor (ER) and progesterone receptor (PR): ER+/PR+: ORQ4-Q1  = 1.96, 95% CI = 1.46-2.64, ptrend <0.0001; ER+/PR-: ORQ4-Q1  = 0.82, 95% CI = 0.40-1.68, ptrend  = 0.51; ER-/PR+: ORQ4-Q1  = 3.23, 95% CI = 0.48-21.9, ptrend  = 0.26; ER-/PR-: ORQ4-Q1  = 1.15, 95% CI = 0.63-2.09, ptrend  = 0.60. The association was observed for both pre- (ORQ4-Q1 = 1.35, 95% CI = 1.05-1.73) and post-menopausal (ORQ4-Q1  = 1.61, 95% CI = 1.03-2.53) breast cancer (pinteraction  = 0.34). In this large consortium study, we confirmed that AMH is associated with breast cancer risk, with a 60% increase in risk for women in the top vs. bottom quartile of AMH.

Analytical and clinical performance of progesterone receptor antibodies in breast cancer

OBJECTIVE

Comparison of analytical and immunohistochemical performance of progesterone receptor (PR) antibodies with correlation to recurrence of invasive breast cancer treated with endocrine therapy.

METHODS

The binding-affinity kinetics of PR clones 1E2, 1A6, 16 and 636 were compared using synthetic peptides derived from identified epitopes on a Biacore T200. A cohort of 351 cases (Hormone Receptor (HR)+/HER2-) were stained for PR expression with immunohistochemistry (IHC) and scored according to ASCO/CAP criteria.

RESULTS

The stability of the antigen/antibody complex was greater for the 1E2 clone compared to 1A6, 16 and 636 clones. PR IHC on archival tissue resulted in 94.3% (299/317) concordance with clones.

CONCLUSION

Clones evaluated in this study had a high level of concordance with IHC despite PR (1E2) demonstrating higher analytical binding properties than other clones. In a minority of cases (1.3% for 1E2 and 2.5% for 636) IHC results could convert estrogen receptor (ER)-/PR- to ER-/PR+ tumors, making these patients potentially eligible for endocrine therapy.

Risk of Second Primary Female Genital Malignancies in Women with Breast Cancer: a SEER Analysis

Breast cancer survivors are at an increased risk of second primary cancers, and the risk factors for the latter may have clinical significance. The aims of our study were to evaluate the incidences and risk factors of second primary female genital cancers (corpus uteri, cervix uteri plus ovary) in a large cohort of breast cancer survivors. Using the Surveillance, Epidemiology, and End Results (SEER) database, we examined the standardized incidence ratio (SIR) and risk factors for second primary female genital cancers observed between 2000 and 2014. Breast cancer survivors had increased SIRs for second corpus uteri cancers and second ovarian cancers and a decreased SIR for second cervical cancers (SIR 1.17, 1.12, and 0.64, respectively). Risk factors of second corpus uteri cancers were the age at first cancer diagnosis, race (black vs. white, aHR = 1.142 95% CI 1.005–1.298), and progesterone receptor (PR) status (PR+ vs. PR−, aHR = 1.131 95% CI 1.004–1.273). In addition, the risk of second ovarian cancer was positively associated with age while inversely associated with race (black vs. white, aHR = 0.691 95% CI 0.555–0.859) and estrogen receptor (ER) status (ER+ vs. ER−, aHR = 0.655 95% CI 0.544–0.788). Age, race, and hormone receptor status are risk factors of developing second female genital cancers among breast cancer survivors. Older age, black race, and a PR+ status in survivors are associated with a higher risk of second corpus uteri cancers. Additionally, older age and an ER− status should increase vigilance for potential second ovarian cancers.