Breast Cancer Res Treat (2014) 147:551–555 DOI 10.1007/s10549-014-3136-y
PRECLINICAL STUDY
Estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 status in invasive breast cancer: a 3,198 cases study at National Cancer Center, China Xinxin Zhu • Jianming Ying • Fang Wang Jie Wang • Hongying Yang
•
Received: 9 September 2014 / Accepted: 11 September 2014 / Published online: 19 September 2014 Ó Springer Science+Business Media New York 2014
Abstract Smears from paraffin sections from 3,198 cases of surgical resection mammary carcinomas were assessed immunohistochemically for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) expressions in National Cancer Center (NCC), China, to explore the correlation of these markers to each other, to tumor histologic subtype, and to explore breast cancer four molecular subtypes clinicopathological characteristics. Pathology material of surgical resection patients presenting to NCC during July 1, 2010– July 1, 2012 were reviewed for patients’ age, tumor size, subtype, grade, and ER, PR, HER2 immunohistochemistry (IHC) status. For HER2 IHC 2? score cases, fluorescence in situ hybridization was used, as the 2007 American society of clinical oncology/college of American pathologists guidelines. There were 3,198 cases, with a median age of 51 years, a mean tumor size of 2.1 cm, and 42.3 % lymph node positivity. Of all cases, 2,506 (78.4 %) were ER?, 2,548 (79.7 %) were PR?, and 816 (25.5 %) were HER2?. Among the four molecular subtypes of breast cancer, luminal A were the majority accounting for 65.3 %, and triple-negative breast cancer accounted for 9.2 %. ER, PR, and HER2 status showed a direct correlation to tumor onset age, tumor type, and grade of ductal carcinoma. Meanwhile the four subtypes of breast cancer differed from onset age, tumor size, lymph node metastasis, and tumor X. Zhu J. Ying J. Wang H. Yang (&) Department of Pathology, Cancer Hospital (Institute), Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China e-mail: [email protected] F. Wang CapitalBio Corporation, 18 Life Science Parkway, Changping District, Beijing 102206, China
grade. This study was an important documentation of Chinese breast cancer patients and the report would serve as a baseline for other future studies. Keywords Breast cancer Estrogen receptor Progesterone receptor Human epidermal growth factor receptor 2 China Abbreviations ER Estrogen receptor PR Progesterone receptor HER2 Human epidermal growth factor receptor 2 FISH Fluorescence in situ hybridization IHC Immunohistochemistry LBA Ligand-binding assay
Introduction The incidence of cancer worldwide is expected to rise to 26.4 million with 17 million deaths by 2030. Most of these new cases of cancer are expected to occur in the developing world, particularly India and China [1]. Breast cancer is the most common malignant tumor seen in females which is a threat to their mental and physical health. Expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) has been found to be of prognostic and therapeutic importance in breast cancer. Immunohistochemistry (IHC) for assessing receptor status is easier, less expensive, safer than ligand-binding assay (LBA), and has an equivalent or even better ability to classify breast cancer molecular subtype and to predict response to effective therapies [2].
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Materials and methods Cases were retrieved from the pathology files at department of Pathology, Cancer Hospital (Institute), Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China during the period July 1, 2010–July 1, 2012. All symptomatic patients presenting to cancer hospital (a national referral center for oncology patients) with the diagnosis of breast cancer and without the second primary tumor were selected. Patients were limited to mastectomies and lumpectomies, because there were sufficient tissues for analysis of the three parameters. Clinicopathological characteristics included age, histological subtype, tumor grade, and lymph node metastasis. Routine hematoxylin and eosin (H&E)-stained 3-lmthickness sections were reviewed. IHC on formalin-fixed paraffin-embedded tissue with 8-lm-thickness section was performed for ER (CONFIRMTM anti-Estrogen Receptor Rabbit Monoclonal Primary Antibody), PR (CONFIRMTM anti-Progesterone Receptor Rabbit Monoclonal Primary Antibody), HER2 (VENTANA anti-HER2/neu Rabbit Monoclonal Primary Antibody) receptors assessment. Among ER, PR, HER2 IHC, each bath ran together with known positive and negative controls. The fixation duration was 6–72 h. Any ambiguity in the report was resolved through discussion with the senior pathologists. Allred scoring system to score ER/PR status was used and tumors were scored as ER/PR positive if score for either was[2 [3]. HER2 scoring was done according to the American society of clinical oncology/college of American pathologists (ASCO/CAP) guidelines as 0, 1?, 2? (equivocal), or 3? positive [4]. HER2 was scored 3? positive if the tumor cells showed complete and strong membrane positivity greater than or equal to 30 %. Scores of 0 or 1? were considered HER2 negative. HER2 IHC 2? (equivocal) score patients were subjected to fluorescence in situ hybridization (FISH) to assess gene amplification at our reference laboratory. If ratio of the HER2/neu/CEP17 signals was C2.2, the FISH test result was considered positive. While cases with a HER2/neu/CEP17 ratio B1.8 were considered negative for HER2 gene amplification. The data were entered and analyzed in SPSS version 18.0. Chi square test (v2) was used for the R 9 C contingency table data. P value \0.05 was considered statistical significant.
Results A total of 3,198 patients (11 for male patients, 3,187 for female patients) with breast carcinoma were analyzed for clinicopathological features. The age range was 19–94 years, with a median of 51 years. The tumor size was
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Breast Cancer Res Treat (2014) 147:551–555 Table 1 Age and estrogen receptor/progesterone receptor, HER2 status Age \50 years (1,435)
Age C50 years (1,763)
ER?
PR?
HER2?
ER?
PR?
HER2?
Cases
1,152
1,204
368
1,354
1,344
448
%
80.3
83.9
25.6
76.8
76.2
25.4
Table 2 Histological types, estrogen receptor, progesterone receptor, and HER2 status Type
ER?
Ductal NOS
%
PR?
%
HER2?
%
Total
2,352
78.0
2,394
79.4
792
26.3
3,017
Mucoid
65
98.5
63
95.5
9
13.6
66
ILC
54
98.2
52
94.5
2
3.6
55
IMC
19
95.0
19
95.0
8
40.0
20
Medullary Metaplastic
5 0
38.5 0
4 2
30.8 25.0
3 1
23.1 12.5
13 8
ICC
7
100
7
100
0
0
7
Apocrine
0
0
2
28.6
0
0
7
IPC
2
66.7
3
100
1
33.3
3
ACC
1
100
1
100
0
0
1
Tubular
1
100
1
100
0
0
2,506
78.4
2,548
79.7
816
Total %
78.4
79.7
1
25.5
3,198
25.5
100
NOS not otherwise specified, ILC invasive lobular carcinoma, IMC invasive micropapillary carcinoma, ICC invasive cribriform carcinoma, IPC invasive papillary carcinoma, ACC adenoid cystic carcinoma
1 mm–15 cm with a mean of 2.1 cm of all 3,198 patients. Lymph nodes were available for histological assessment in 3,080 cases. Of the 3,080 cases that had sentinel node examination, axillary sampling, or axillary dissection, 1,302 (42.3 %) had positive lymph nodes metastasis. As shown in Table 1, the receptor expression and the onset age of patients were analyzed. Of 1,435 younger patients (\50 years), 1,152 (80.3 %) were ER?, 1,204 (83.9 %) were PR?, and 368 (25.6 %) were HER2?. Whereas of 1,763 patients aged C50 years, 1,354 (76.8 %) were ER?, 1,344 (76.2 %) were PR?, and 448 (25.4 %) were HER2?. There were higher ER, PR positivity rates in younger patients (\50 years) compared to older ones (C50 years) (80.3 vs 76.8, 83.9 vs 76.2 % respectively), and were statistical significant (P \ 0.05). For HER2? tumors, a similar proportion of cases were below and above the age of 50 years (25.6 vs 25.4, P [ 0.05). Table 2 shows the ER, PR, and HER2 status in relation to histological type. Invasive ductal carcinoma (IDC) not otherwise specified (NOS) dominated with 3,017 (94.3 %) cases, followed by mucinous carcinoma with 66 (2.1 %).
Breast Cancer Res Treat (2014) 147:551–555
553
Table 3 Ductal carcinoma grading and ER, PR, HER2 status Grade
No.
HER2?
%
ER?
%
PR?
%
3
882
343
38.9
479
54.3
540
61.2
2
1,840
405
22.0
1,601
87.0
1,582
86.0
1
295
44
14.9
272
92.2
272
92.2
3,017
792
26.3
2,352
78.0
2,394
79.4
Total
Invasive lobular carcinoma accounted for 55 (1.7 %), invasive micropapillary carcinoma for 20 (0.6 %), medullary carcinoma for 13 (0.4 %), metaplastic carcinoma for 8 (0.3 %), invasive cribriform carcinoma and apocrine carcinoma for 7 (0.2 %) respectively, 3 (0.09 %) for invasive papillary carcinoma, and one each (0.03 %) for adenoid cystic and tubular carcinoma. Of all patients, 2,697 (84.3 %) were ER/PR positive (ER/PR?) and 501 (15.7 %) were ER/PR negative (ER-/ PR-). In the 3,198 cases on which HER2 was performed, 644 cases were HER2 3? positive and 965 were 2? (equivocal). Of the equivocal patients tested by FISH further, 172 were positive for HER2, giving a total HER2 positive number of 816 cases (25.5 %). Triple-negative breast cancers (TNBC) constituted 9.2 % (293/3,198) of the total cases. Of 3,017 IDC NOS cases 2,352 (78.0 %) were ER?; 2,394 (79.4 %) were PR?. All invasive cribriform, adenoid cystic and tubular carcinomas were ER and PR positive. Almost all mucosa, invasive lobular, invasive micropapillary carcinoma cases were ER and PR positive. A close relation could be discovered between ER and PR positive expression. It has been shown in the literature that PR expression commonly parallels ER expression in breast cancer [5]. For ductal NOS cases, 792 (26.3 %) were HER2?. All the seven invasive cribriform, apocrine, adenoid cystic and tubular carcinomas were HER2-. Table 3 demonstrates the grade (G) of 3,017 IDC cases correlated with ER, PR, and HER2 status. IDC G2 was the most common, with 1,840 cases (61.0 %), followed by G3 with 882 (29.2 %), and G1 with 295 (9.8 %) cases. It also shows the inverse relationship of ER/PR and HER2 positivity with tumor grade. While 92.2 % of G1, 87.0 % of G2, 54.3 % of G3 were ER? and 92.2 % of G1, 86.0 % of G2, 61.2 % of G3 were PR?, it was noted that 38.9 % of G3, 22.0 % of G2, and 14.9 % of G1 were HER2 positive (HER2?). Breast cancer is a heterogeneous disease whose component includes luminal A (HER2-/ER/PR?), luminal B (HER2?/ER/PR?), HER-2 overexpression (HER2?/ ER-/PR-), and triple-negative (HER2-/ER-/PR-) four molecular subtypes, and luminal A is the majority [6, 7]. A better understanding of molecular subtypes would be of benefit to therapeutic decision-making and to conducting
appropriate follow-ups. Table 4 discusses four molecular subtypes of breast cancer and their clinicopathological characteristics. Of all 3,198 patients, 2,089 were HER2-/ ER/PR? (luminal A, 65.3 %), 608 were HER2?/ER/PR? (luminal B, 19.0 %), and 208 were HER2?/ER-/PR(HER2 overexpression, 6.5 %). The triple-negative phenotype (TNBC ER-/PR-/HER2-) accounted for 293 cases (9.2 %). The Chi squared (v2) values that evaluated the distribution of tumor characteristics across the molecular subtypes were statistically significant (P \ 0.05). This indicated that there was an association between the subtype and tumor clinicopathological characteristics. Age was a significant factor in HER2? (66.8 % older than 50 years vs 33.2 % younger than 50 years) and TNBC tumors (57.3 vs 42.7 %). Higher grade tumors (G3) at presentation were mostly observed in HER2? (55.2 %) and TNBC (64.4 %), while were less observed in luminal A (18.5 %). Tumors of higher stage were more likely to be HER2? (49.5 %), luminal B (48.1 %), and TNBC (45.7 %) than luminal A (38.4 %). These results also supported earlier research that found that larger tumors were associated with the TN and ER-/PR-/HER2? subtypes [8].
Discussion ER, PR, HER2 overexpressions are associated with clinical outcomes and are important predictive and prognostic factors. ER and PR are the most widely studied markers in breast tissue. The relationship between targeted expression (ER/PR) and efficacy of endocrine therapy is well-established [9, 10]. It also has been shown that PR status is associated independently with disease-free and overall survival, and ER?/PR? patients have a better prognosis than ER?/PR- patients [11]. HER2 is a transmembrane receptor protein with tyrosine kinase activity, and signaling through HER2 activation promotes cell proliferation [12]. HER2-overexpression association with poor prognosis in breast cancer and the great potential of technologies to produce monoclonal antibodies generated great enthusiasm in academic laboratories in the 1980s [13]. The development of Trastuzumab (Herceptin, Genentech, South San Francisco, CA, USA) monoclonal antibody treatment represented a paradigm shift in oncology from non-specific chemotherapy to a molecularly targeted therapy [14, 15]. Reports have shown that HER2-targeted agent (Trastuzumab) is effective in metastatic and adjuvant settings [16]. In this study, the receptor expression statuses in 3,198 breast cancer patients were assessed. Evaluation of ER, PR, and HER2 as molecular markers for prediction in breast cancer is of great importance in clinical practice and is directly related to the response rate of endocrine and targeted therapies [17].
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Table 4 Molecular subtype of breast cancer and clinicopathological features Age (mean)
Luminal A
Luminal B
HER2?
n
n
n
%
52.2
%
50.3
TNBC %
52.6
n
P-value %
52.0
Age category
0.001
Age (\50 years)
942
45.1
299
49.2
69
33.2
125
42.7
Age (50? years)
1,147
54.9
309
50.8
139
66.8
168
57.3
Tumor size (mean)
2.0
2.2
2.3
2.2 \0.001
pT T1
1,285
61.5
317
52.1
105
50.5
158
53.9
T2
779
37.3
284
46.7
97
46.6
132
45.1
T3
24
1.1
7
1.2
6
2.9
3
1.0
T4
1
0.05
0
0
0
0
0
0
865
43.3
265
44.8
91
44.8
81
28.2
1,134
56.7
326
55.2
112
55.2
206
71.8
G1
245
12.6
34
5.8
10
4.9
6
2.2
G2
1,342
68.9
324
55.0
81
39.9
93
33.5
G3
360
18.5
231
39.2
112
55.2
179
64.4
2,089
65.3
608
19.0
208
6.5
293
9.2
LNM Present Absent
\0.001
\0.001
Grade HER2? HER2 overexpression, TNBC triple-negative breast cancer, LNM lymph node metastasis
Total
As seen in this study, the median age of patients was 51 and was younger by about a decade compared to the west [2]. The results indicated a mean size of 2.1 cm, with 42.3 % lymph node metastasis which was similar to previous report. [17]. It is shown that, approximately 75 % of breast cancer cases in the US women are ER?, with a range from 60 to 85 %; approximately 65 % of ER? breast cancers are also PR?, and 25–30 % breast carcinoma is HER2?. [18, 19]. In the study, ER?, HER2? expression rates were similar to the reports, while PR? expression rate was a little higher (73.7 %), which demonstrated that PR expression commonly paralleled ER expression. In this presentation, ductal carcinoma was the dominant histological type (94.3 %). Mucinous carcinoma was second most frequent at 2.1 %, followed by invasive lobular carcinoma, and the remaining rare histological types. A direct relation was found between ER, PR positivity rates, and both invasive carcinoma type and histological grade. All invasive cribriform, lobular, adenoid cystic carcinomas, almost all mucinous, invasive lobular carcinomas, and a majority of IDC, were ER/PR?. Furthermore, as shown in Table 3, 92.2 % of G1, 87.0 % of G2, and only 54.3 % of G3 ductal carcinoma were ER?. At the same time, 92.2 % of G1, 86.0 % of G2, and 61.2 % of G3 ductal carcinoma were PR?. In contrast, the reverse was observed for HER2? expression. Of 816 HER2? cases, 792 were IDC (97.1 %), 9 (1.1 %) mucinous, 8 (1.0 %) invasive micropapillary, three medullary, two invasive lobular, one metaplastic, and
123
(3,198)
one invasive papillary carcinomas (Table 2). Only 14.9 % of G1 ductal carcinomas were HER2?, 22.0 % of G2 were positive, whereas 38.9 % of G3 were HER2? (Table 3). This shows that the higher the grade, the more likely that ductal carcinoma will be(HER2?/ER-/PR-). Recent studies have resulted in the identification of several molecularly distinct breast cancer subgroups that have different targeted therapies. So the correct characterization for different molecular subtypes was the foundation of personalized treatment and prognostic evaluation [20]. Table 4 aimed to identify the frequency and clinicopathological characteristics of these four subtypes in our population. Luminal A accounted for 65.3 % of cases, luminal B for 19.0 %, HER2 accounted for 6.5 %, and triple negative was 9.2 %. Luminal A was the majority, while TNBC had a lower rate compared with the western [21]. Summarily speaking, this study from a large National Cancer Center in China shows that breast cancer ER/HER2 status and the features of four molecular subtypes are not different from reported literature previously, with approximately 78.0 % ER positivity and 26.3 % HER2 positivity in IDC. However, a difference exists in the relatively lower ER positivity in patients aged C50 years, the higher percentage of PR positivity among invasive carcinoma and the lower percentage of TNBC. ER, PR, HER2 have notable correlations with invasive breast cancer type and IDC grade. What is more, four molecular subtypes of breast cancer differ from onset age, tumor stage, lymph node metastasis, and grade. This study and report will act
Breast Cancer Res Treat (2014) 147:551–555
as a baseline for future clinical studies and strategies for targeted therapy.
Conflict of interest
555
11.
The authors declare no conflict of interests. 12.
References 13. 1. Akarolo-Anthony SN, Ogundiran TO, Adebamowo CA (2010) Emerging breast cancer epidemic: evidence from Africa. Breast Cancer Res 12(Suppl 4):S8 2. Singh R, Gupta S, Pawar SB, Pawar RS, Gandham SV, Prabhudesai S (2014) Evaluation of ER, PR and HER-2 receptor expression in breast cancer patients presenting to a semi urban cancer centre in Western India. J Cancer Res Ther 10(1):26–28 3. Harvey JM, Clark GM, Osborne CK, Allred DC (1999) Estrogen receptor status by immunohistochemistry is superior to the ligand-binding assay for predicting response to adjuvant endocrine therapy in breast cancer. J Clin Oncol 17(5):1474–1481 4. Raji A, Lurie RH (2007) Human epidermal growth factor receptor 2 testing recommendation. Arch Pathol Lab Med 131(9):1330–1331; author reply 1331–1333 5. Zhou XL, Fan W, Yang G, Yu MX (2014) The clinical significance of PR, ER, NF-kappa B, and TNF-alpha in breast cancer. Dis Markers 2014:494581 6. Carey LA, Perou CM, Livasy CA, Dressler LG, Cowan D, Conway K, Karaca G, Troester MA, Tse CK, Edmiston S et al (2006) Race, breast cancer subtypes, and survival in the Carolina Breast Cancer Study. JAMA 295(21):2492–2502 7. Brenton JD, Carey LA, Ahmed AA, Caldas C (2005) Molecular classification and molecular forecasting of breast cancer: ready for clinical application? J Clin Oncol 23(29):7350–7360 8. Parise CA, Bauer KR, Brown MM, Caggiano V (2009) Breast cancer subtypes as defined by the estrogen receptor (ER), progesterone receptor (PR), and the human epidermal growth factor receptor 2 (HER2) among women with invasive breast cancer in California, 1999–2004. Breast J 15(6):593–602 9. Karger S, Freiburg GH (2010) Pathologists’ guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer. Breast Care (Basel) 5(3):185–187 10. Althuis MD, Fergenbaum JH, Garcia-Closas M, Brinton LA, Madigan MP, Sherman ME (2004) Etiology of hormone receptor-
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PRECLINICAL STUDY
Estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 status in invasive breast cancer: a 3,198 cases study at National Cancer Center, China Xinxin Zhu • Jianming Ying • Fang Wang Jie Wang • Hongying Yang
•
Received: 9 September 2014 / Accepted: 11 September 2014 / Published online: 19 September 2014 Ó Springer Science+Business Media New York 2014
Abstract Smears from paraffin sections from 3,198 cases of surgical resection mammary carcinomas were assessed immunohistochemically for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) expressions in National Cancer Center (NCC), China, to explore the correlation of these markers to each other, to tumor histologic subtype, and to explore breast cancer four molecular subtypes clinicopathological characteristics. Pathology material of surgical resection patients presenting to NCC during July 1, 2010– July 1, 2012 were reviewed for patients’ age, tumor size, subtype, grade, and ER, PR, HER2 immunohistochemistry (IHC) status. For HER2 IHC 2? score cases, fluorescence in situ hybridization was used, as the 2007 American society of clinical oncology/college of American pathologists guidelines. There were 3,198 cases, with a median age of 51 years, a mean tumor size of 2.1 cm, and 42.3 % lymph node positivity. Of all cases, 2,506 (78.4 %) were ER?, 2,548 (79.7 %) were PR?, and 816 (25.5 %) were HER2?. Among the four molecular subtypes of breast cancer, luminal A were the majority accounting for 65.3 %, and triple-negative breast cancer accounted for 9.2 %. ER, PR, and HER2 status showed a direct correlation to tumor onset age, tumor type, and grade of ductal carcinoma. Meanwhile the four subtypes of breast cancer differed from onset age, tumor size, lymph node metastasis, and tumor X. Zhu J. Ying J. Wang H. Yang (&) Department of Pathology, Cancer Hospital (Institute), Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China e-mail: [email protected] F. Wang CapitalBio Corporation, 18 Life Science Parkway, Changping District, Beijing 102206, China
grade. This study was an important documentation of Chinese breast cancer patients and the report would serve as a baseline for other future studies. Keywords Breast cancer Estrogen receptor Progesterone receptor Human epidermal growth factor receptor 2 China Abbreviations ER Estrogen receptor PR Progesterone receptor HER2 Human epidermal growth factor receptor 2 FISH Fluorescence in situ hybridization IHC Immunohistochemistry LBA Ligand-binding assay
Introduction The incidence of cancer worldwide is expected to rise to 26.4 million with 17 million deaths by 2030. Most of these new cases of cancer are expected to occur in the developing world, particularly India and China [1]. Breast cancer is the most common malignant tumor seen in females which is a threat to their mental and physical health. Expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) has been found to be of prognostic and therapeutic importance in breast cancer. Immunohistochemistry (IHC) for assessing receptor status is easier, less expensive, safer than ligand-binding assay (LBA), and has an equivalent or even better ability to classify breast cancer molecular subtype and to predict response to effective therapies [2].
123
552
Materials and methods Cases were retrieved from the pathology files at department of Pathology, Cancer Hospital (Institute), Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China during the period July 1, 2010–July 1, 2012. All symptomatic patients presenting to cancer hospital (a national referral center for oncology patients) with the diagnosis of breast cancer and without the second primary tumor were selected. Patients were limited to mastectomies and lumpectomies, because there were sufficient tissues for analysis of the three parameters. Clinicopathological characteristics included age, histological subtype, tumor grade, and lymph node metastasis. Routine hematoxylin and eosin (H&E)-stained 3-lmthickness sections were reviewed. IHC on formalin-fixed paraffin-embedded tissue with 8-lm-thickness section was performed for ER (CONFIRMTM anti-Estrogen Receptor Rabbit Monoclonal Primary Antibody), PR (CONFIRMTM anti-Progesterone Receptor Rabbit Monoclonal Primary Antibody), HER2 (VENTANA anti-HER2/neu Rabbit Monoclonal Primary Antibody) receptors assessment. Among ER, PR, HER2 IHC, each bath ran together with known positive and negative controls. The fixation duration was 6–72 h. Any ambiguity in the report was resolved through discussion with the senior pathologists. Allred scoring system to score ER/PR status was used and tumors were scored as ER/PR positive if score for either was[2 [3]. HER2 scoring was done according to the American society of clinical oncology/college of American pathologists (ASCO/CAP) guidelines as 0, 1?, 2? (equivocal), or 3? positive [4]. HER2 was scored 3? positive if the tumor cells showed complete and strong membrane positivity greater than or equal to 30 %. Scores of 0 or 1? were considered HER2 negative. HER2 IHC 2? (equivocal) score patients were subjected to fluorescence in situ hybridization (FISH) to assess gene amplification at our reference laboratory. If ratio of the HER2/neu/CEP17 signals was C2.2, the FISH test result was considered positive. While cases with a HER2/neu/CEP17 ratio B1.8 were considered negative for HER2 gene amplification. The data were entered and analyzed in SPSS version 18.0. Chi square test (v2) was used for the R 9 C contingency table data. P value \0.05 was considered statistical significant.
Results A total of 3,198 patients (11 for male patients, 3,187 for female patients) with breast carcinoma were analyzed for clinicopathological features. The age range was 19–94 years, with a median of 51 years. The tumor size was
123
Breast Cancer Res Treat (2014) 147:551–555 Table 1 Age and estrogen receptor/progesterone receptor, HER2 status Age \50 years (1,435)
Age C50 years (1,763)
ER?
PR?
HER2?
ER?
PR?
HER2?
Cases
1,152
1,204
368
1,354
1,344
448
%
80.3
83.9
25.6
76.8
76.2
25.4
Table 2 Histological types, estrogen receptor, progesterone receptor, and HER2 status Type
ER?
Ductal NOS
%
PR?
%
HER2?
%
Total
2,352
78.0
2,394
79.4
792
26.3
3,017
Mucoid
65
98.5
63
95.5
9
13.6
66
ILC
54
98.2
52
94.5
2
3.6
55
IMC
19
95.0
19
95.0
8
40.0
20
Medullary Metaplastic
5 0
38.5 0
4 2
30.8 25.0
3 1
23.1 12.5
13 8
ICC
7
100
7
100
0
0
7
Apocrine
0
0
2
28.6
0
0
7
IPC
2
66.7
3
100
1
33.3
3
ACC
1
100
1
100
0
0
1
Tubular
1
100
1
100
0
0
2,506
78.4
2,548
79.7
816
Total %
78.4
79.7
1
25.5
3,198
25.5
100
NOS not otherwise specified, ILC invasive lobular carcinoma, IMC invasive micropapillary carcinoma, ICC invasive cribriform carcinoma, IPC invasive papillary carcinoma, ACC adenoid cystic carcinoma
1 mm–15 cm with a mean of 2.1 cm of all 3,198 patients. Lymph nodes were available for histological assessment in 3,080 cases. Of the 3,080 cases that had sentinel node examination, axillary sampling, or axillary dissection, 1,302 (42.3 %) had positive lymph nodes metastasis. As shown in Table 1, the receptor expression and the onset age of patients were analyzed. Of 1,435 younger patients (\50 years), 1,152 (80.3 %) were ER?, 1,204 (83.9 %) were PR?, and 368 (25.6 %) were HER2?. Whereas of 1,763 patients aged C50 years, 1,354 (76.8 %) were ER?, 1,344 (76.2 %) were PR?, and 448 (25.4 %) were HER2?. There were higher ER, PR positivity rates in younger patients (\50 years) compared to older ones (C50 years) (80.3 vs 76.8, 83.9 vs 76.2 % respectively), and were statistical significant (P \ 0.05). For HER2? tumors, a similar proportion of cases were below and above the age of 50 years (25.6 vs 25.4, P [ 0.05). Table 2 shows the ER, PR, and HER2 status in relation to histological type. Invasive ductal carcinoma (IDC) not otherwise specified (NOS) dominated with 3,017 (94.3 %) cases, followed by mucinous carcinoma with 66 (2.1 %).
Breast Cancer Res Treat (2014) 147:551–555
553
Table 3 Ductal carcinoma grading and ER, PR, HER2 status Grade
No.
HER2?
%
ER?
%
PR?
%
3
882
343
38.9
479
54.3
540
61.2
2
1,840
405
22.0
1,601
87.0
1,582
86.0
1
295
44
14.9
272
92.2
272
92.2
3,017
792
26.3
2,352
78.0
2,394
79.4
Total
Invasive lobular carcinoma accounted for 55 (1.7 %), invasive micropapillary carcinoma for 20 (0.6 %), medullary carcinoma for 13 (0.4 %), metaplastic carcinoma for 8 (0.3 %), invasive cribriform carcinoma and apocrine carcinoma for 7 (0.2 %) respectively, 3 (0.09 %) for invasive papillary carcinoma, and one each (0.03 %) for adenoid cystic and tubular carcinoma. Of all patients, 2,697 (84.3 %) were ER/PR positive (ER/PR?) and 501 (15.7 %) were ER/PR negative (ER-/ PR-). In the 3,198 cases on which HER2 was performed, 644 cases were HER2 3? positive and 965 were 2? (equivocal). Of the equivocal patients tested by FISH further, 172 were positive for HER2, giving a total HER2 positive number of 816 cases (25.5 %). Triple-negative breast cancers (TNBC) constituted 9.2 % (293/3,198) of the total cases. Of 3,017 IDC NOS cases 2,352 (78.0 %) were ER?; 2,394 (79.4 %) were PR?. All invasive cribriform, adenoid cystic and tubular carcinomas were ER and PR positive. Almost all mucosa, invasive lobular, invasive micropapillary carcinoma cases were ER and PR positive. A close relation could be discovered between ER and PR positive expression. It has been shown in the literature that PR expression commonly parallels ER expression in breast cancer [5]. For ductal NOS cases, 792 (26.3 %) were HER2?. All the seven invasive cribriform, apocrine, adenoid cystic and tubular carcinomas were HER2-. Table 3 demonstrates the grade (G) of 3,017 IDC cases correlated with ER, PR, and HER2 status. IDC G2 was the most common, with 1,840 cases (61.0 %), followed by G3 with 882 (29.2 %), and G1 with 295 (9.8 %) cases. It also shows the inverse relationship of ER/PR and HER2 positivity with tumor grade. While 92.2 % of G1, 87.0 % of G2, 54.3 % of G3 were ER? and 92.2 % of G1, 86.0 % of G2, 61.2 % of G3 were PR?, it was noted that 38.9 % of G3, 22.0 % of G2, and 14.9 % of G1 were HER2 positive (HER2?). Breast cancer is a heterogeneous disease whose component includes luminal A (HER2-/ER/PR?), luminal B (HER2?/ER/PR?), HER-2 overexpression (HER2?/ ER-/PR-), and triple-negative (HER2-/ER-/PR-) four molecular subtypes, and luminal A is the majority [6, 7]. A better understanding of molecular subtypes would be of benefit to therapeutic decision-making and to conducting
appropriate follow-ups. Table 4 discusses four molecular subtypes of breast cancer and their clinicopathological characteristics. Of all 3,198 patients, 2,089 were HER2-/ ER/PR? (luminal A, 65.3 %), 608 were HER2?/ER/PR? (luminal B, 19.0 %), and 208 were HER2?/ER-/PR(HER2 overexpression, 6.5 %). The triple-negative phenotype (TNBC ER-/PR-/HER2-) accounted for 293 cases (9.2 %). The Chi squared (v2) values that evaluated the distribution of tumor characteristics across the molecular subtypes were statistically significant (P \ 0.05). This indicated that there was an association between the subtype and tumor clinicopathological characteristics. Age was a significant factor in HER2? (66.8 % older than 50 years vs 33.2 % younger than 50 years) and TNBC tumors (57.3 vs 42.7 %). Higher grade tumors (G3) at presentation were mostly observed in HER2? (55.2 %) and TNBC (64.4 %), while were less observed in luminal A (18.5 %). Tumors of higher stage were more likely to be HER2? (49.5 %), luminal B (48.1 %), and TNBC (45.7 %) than luminal A (38.4 %). These results also supported earlier research that found that larger tumors were associated with the TN and ER-/PR-/HER2? subtypes [8].
Discussion ER, PR, HER2 overexpressions are associated with clinical outcomes and are important predictive and prognostic factors. ER and PR are the most widely studied markers in breast tissue. The relationship between targeted expression (ER/PR) and efficacy of endocrine therapy is well-established [9, 10]. It also has been shown that PR status is associated independently with disease-free and overall survival, and ER?/PR? patients have a better prognosis than ER?/PR- patients [11]. HER2 is a transmembrane receptor protein with tyrosine kinase activity, and signaling through HER2 activation promotes cell proliferation [12]. HER2-overexpression association with poor prognosis in breast cancer and the great potential of technologies to produce monoclonal antibodies generated great enthusiasm in academic laboratories in the 1980s [13]. The development of Trastuzumab (Herceptin, Genentech, South San Francisco, CA, USA) monoclonal antibody treatment represented a paradigm shift in oncology from non-specific chemotherapy to a molecularly targeted therapy [14, 15]. Reports have shown that HER2-targeted agent (Trastuzumab) is effective in metastatic and adjuvant settings [16]. In this study, the receptor expression statuses in 3,198 breast cancer patients were assessed. Evaluation of ER, PR, and HER2 as molecular markers for prediction in breast cancer is of great importance in clinical practice and is directly related to the response rate of endocrine and targeted therapies [17].
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Table 4 Molecular subtype of breast cancer and clinicopathological features Age (mean)
Luminal A
Luminal B
HER2?
n
n
n
%
52.2
%
50.3
TNBC %
52.6
n
P-value %
52.0
Age category
0.001
Age (\50 years)
942
45.1
299
49.2
69
33.2
125
42.7
Age (50? years)
1,147
54.9
309
50.8
139
66.8
168
57.3
Tumor size (mean)
2.0
2.2
2.3
2.2 \0.001
pT T1
1,285
61.5
317
52.1
105
50.5
158
53.9
T2
779
37.3
284
46.7
97
46.6
132
45.1
T3
24
1.1
7
1.2
6
2.9
3
1.0
T4
1
0.05
0
0
0
0
0
0
865
43.3
265
44.8
91
44.8
81
28.2
1,134
56.7
326
55.2
112
55.2
206
71.8
G1
245
12.6
34
5.8
10
4.9
6
2.2
G2
1,342
68.9
324
55.0
81
39.9
93
33.5
G3
360
18.5
231
39.2
112
55.2
179
64.4
2,089
65.3
608
19.0
208
6.5
293
9.2
LNM Present Absent
\0.001
\0.001
Grade HER2? HER2 overexpression, TNBC triple-negative breast cancer, LNM lymph node metastasis
Total
As seen in this study, the median age of patients was 51 and was younger by about a decade compared to the west [2]. The results indicated a mean size of 2.1 cm, with 42.3 % lymph node metastasis which was similar to previous report. [17]. It is shown that, approximately 75 % of breast cancer cases in the US women are ER?, with a range from 60 to 85 %; approximately 65 % of ER? breast cancers are also PR?, and 25–30 % breast carcinoma is HER2?. [18, 19]. In the study, ER?, HER2? expression rates were similar to the reports, while PR? expression rate was a little higher (73.7 %), which demonstrated that PR expression commonly paralleled ER expression. In this presentation, ductal carcinoma was the dominant histological type (94.3 %). Mucinous carcinoma was second most frequent at 2.1 %, followed by invasive lobular carcinoma, and the remaining rare histological types. A direct relation was found between ER, PR positivity rates, and both invasive carcinoma type and histological grade. All invasive cribriform, lobular, adenoid cystic carcinomas, almost all mucinous, invasive lobular carcinomas, and a majority of IDC, were ER/PR?. Furthermore, as shown in Table 3, 92.2 % of G1, 87.0 % of G2, and only 54.3 % of G3 ductal carcinoma were ER?. At the same time, 92.2 % of G1, 86.0 % of G2, and 61.2 % of G3 ductal carcinoma were PR?. In contrast, the reverse was observed for HER2? expression. Of 816 HER2? cases, 792 were IDC (97.1 %), 9 (1.1 %) mucinous, 8 (1.0 %) invasive micropapillary, three medullary, two invasive lobular, one metaplastic, and
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(3,198)
one invasive papillary carcinomas (Table 2). Only 14.9 % of G1 ductal carcinomas were HER2?, 22.0 % of G2 were positive, whereas 38.9 % of G3 were HER2? (Table 3). This shows that the higher the grade, the more likely that ductal carcinoma will be(HER2?/ER-/PR-). Recent studies have resulted in the identification of several molecularly distinct breast cancer subgroups that have different targeted therapies. So the correct characterization for different molecular subtypes was the foundation of personalized treatment and prognostic evaluation [20]. Table 4 aimed to identify the frequency and clinicopathological characteristics of these four subtypes in our population. Luminal A accounted for 65.3 % of cases, luminal B for 19.0 %, HER2 accounted for 6.5 %, and triple negative was 9.2 %. Luminal A was the majority, while TNBC had a lower rate compared with the western [21]. Summarily speaking, this study from a large National Cancer Center in China shows that breast cancer ER/HER2 status and the features of four molecular subtypes are not different from reported literature previously, with approximately 78.0 % ER positivity and 26.3 % HER2 positivity in IDC. However, a difference exists in the relatively lower ER positivity in patients aged C50 years, the higher percentage of PR positivity among invasive carcinoma and the lower percentage of TNBC. ER, PR, HER2 have notable correlations with invasive breast cancer type and IDC grade. What is more, four molecular subtypes of breast cancer differ from onset age, tumor stage, lymph node metastasis, and grade. This study and report will act
Breast Cancer Res Treat (2014) 147:551–555
as a baseline for future clinical studies and strategies for targeted therapy.
Conflict of interest
555
11.
The authors declare no conflict of interests. 12.
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