Progesterone Receptor Values Research Articles

St. Gallen endocrine response classes predict recurrence rates over time

BackgroundIn 2007 the St. Gallen consensus panel defined three endocrine response classes: highly endocrine responsive (ER-H), incomplete endocrine responsive (ER-I) and non-endocrine responsive tumours (ER-N). However, it is uncertain whether ER-I tumours are less responsive than ER-H tumours. We investigated whether recurrence rates vary over time between response classes. Additionally, we investigated the most predictive response class definition for tamoxifen benefit. Patients and methodsWe recollected tumours from 646 patients who participated in a randomized trial of adjuvant tamoxifen vs. observation. Estrogen receptor (ER), progesterone receptor (PgR), HER2 status and tumour grade were revised centrally. St. Gallen classes were evaluated for recurrence free interval (RFI). Change in hazards over time was assessed. Subsequently, 6 alternative response class definitions were compared to optimize the cut-off for PgR and ER. ResultsSchoenfeld residuals indicate a failure of proportional hazards between the endocrine response groups (p = 0.0001). The HR for recurrence risk shifted over time with the ER-H group initially being at lower risk (HR ER-H vs. ER-I 0.5), but after six years the recurrence risk increased (HR 1.9). The cut-off values for ER and PgR that statistically best discriminated RFI in the first 4 years for lymph node positive patients were ER ≥ 50% and PgR ≥ 75%. ConclusionWe demonstrated a marked variability in endocrine therapy benefit. Patients with ER-H tumours have a larger benefit during adjuvant tamoxifen and in the first years after accomplishing of the therapy, but suffer from late recurrences. This might have implications for optimal treatment duration.

Abstract P3-04-04: The prognostic effect of a negative progesterone receptor (PgR) by immunohistochemistry (IHC) in luminal HER-2 negative breast cancer (BC) by age at diagnosis: 10 years follow-up study

Abstract Background After menopause, an absent PgR predicts distant metastases (DM) in patients with ER positive HER-2 negative invasive BC. Yamamoto et al. (JCO 2013) questioned the prognostic effect of PR in premenopausal patients, as ovarian estrogens might affect PgR expression. We investigated the effect of PgR on DM free interval (DMFI) and BC specific survival (BCSS) by age at diagnosis as surrogate marker for menopause. Patients and methods Retrospective data of consecutive patients with a primary operable ER positive HER-2 negative BC (1/1/2000 - 31/12/2009) were retrieved from our prospectively managed database. Cases that received neo-adjuvant chemotherapy or were operated in another hospital, were excluded. BC with missing values for PgR, grade or lymph node status and/or lost to follow-up were excluded in some subgroup analyses. A multivariate (MV) competing risk model for DMFI and BCSS was established considering age at diagnosis (age ≤50 yrs vs >50 yrs), PgR status, tumor grade (1-3), tumor size (mm) and lymph node status (neg/pos). Steroid receptors were considered positive if ≥1% stained on IHC. Differential prognostic effects of these variables according to PR or age were tested by means of interaction effects. Only significant interactions were included. Results We included 3326 BCs (8 with missing PgR status); 2911 (87.5%) PgR positive [870 (26.2%) ≤50 yrs and 2041 (61.4%) >50 yrs] and 407 (12.5%) PgR negative [68 (2.0%) ≤50 yrs and 339 (10.2%) >50 yrs]. In absolute numbers and compared to PgR positive BCs, PgR negative cases >50yrs had more DM if grade 3 and more BCSS for all grades. In BC ≤50 yrs these differences were not found, but only 7.2% were PgR negative (Tab.1). Results from the MV models showed a significant interaction with PgR on DMFI and BCSS (respectively p=0.01 and p=0.002) resulting in higher risk of DM (HR, 1.9; 95% CI, 1.4-2.7; p=0.001) and BCSS (HR, 2.4; 95% CI, 1.6-3.7; p<0.001) when PgR was absent for BCP >50 yrs. This difference in DMFI and BCSS according to PgR status was not found in BC ≤50 yrs (Tab.2). Table 1. Number of BCP with distant metastasis and BCSS according to age (yrs), PgR status(+/-) and tumor grade.Distant Metastatic DiseaseBreast Cancer Specific Survival≤50 yrs>50 yrs≤50 yrs>50 yrsPgR+PgR-PgR+PgR-PgR+PgR-PgR+PgR-Grade 1-245/607 (7.4%)5/42 (11.9%)66/1512 (4.4%)11/226 (4.9%)28/607 (4.6%)2/42 (4.8%)33/1511 (2.1%)7/226 (3.1%)Grade 350/263 (19.0%)4/26 (15.4%)69/529 (13.0%)35/113 (31.0%)31/263 (11.8%)2/26 (7.7%)44/529 (8.3%)26/113 (23.0%) Table 2. Results of MV model including significant main effects and interaction effects between tumor characteristics, age and PgR status on DMFI and BCSS. 95% Confidence interval InteractionsHazard ratioLower limitUpper limitP-valueA. BMFIPgR Neg. vs Pos. |-50yrs0.7840.3951.5560.4869PgR Neg. vs Pos. |+50yrs1.9371.3862.7090.0001B. BCSSPgR Neg. vs Pos. |-50yrs0.5750.2081.5880.2854PgR Neg. vs Pos. |+50yrs2.4391.6203.672<.0001 Conclusions A negative PgR is only prognostic for DMFI and BCSS in women aged >50 at diagnosis. There was no difference of PgR for these endpoints in patients ≤50 yrs at diagnosis but PR negativity is rare in this age group. Citation Format: Siel JAR Olbrecht, Kathleen Van Asten, Annouschka Laenen, Chantal Remmerie, Wildiers Hans, Floris Guiseppe, Christiaens Marie-Rose, Vergote Ignace, Neven Patrick. The prognostic effect of a negative progesterone receptor (PgR) by immunohistochemistry (IHC) in luminal HER-2 negative breast cancer (BC) by age at diagnosis: 10 years follow-up study [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-04-04.

Prognostic significance of Ki-67 index value at the primary breast tumor in recurrent breast cancer.

The Ki-67 index value is a prognostic factor in primary breast cancer and is a proliferation marker that also distinguishes between luminal type A and type B breast cancer. Moreover, a change in Ki-67 index values due to treatment and recurrence is considered to be important in treating breast cancer. In this study, we investigated whether the baseline Ki-67 value in the primary tumor is useful as a prognostic factor following disease recurrence. Immunohistochemical analysis of the Ki-67 index was performed on 4,701 patients with primary breast cancer from 1987 until March, 2013. Among these patients, there were 666 consecutive cases exhibiting recurrence after primary surgery. The fraction of proliferating cells was based on a count of at least 500 tumor cells in the area including the hot spot. The Ki-67 values were divided into 3 groups, namely <20, ≥20 and ≥50%. The investigated items included estrogen receptor (ER), progesterone receptor (PgR), human epidermal growth factor receptor 2 (HER2), tumor size, nodal status for the primary tumor, recurrence site (soft tissue, bone and viscera) and disease-free interval (DFI). The Cox's proportional hazard model was used to perform univariate and multivariate analyses of the factors associated with overall survival (OS) following recurrence. The median follow-up period was 65.9 months in the surviving group. The median Ki-67 value at baseline was 20% in all the cases and 27% in the recurrent cases. The Ki-67 values were low (24%) in patients with bone metastasis and significantly higher in patients with liver or brain metastasis (38 and 55%, respectively). Moreover, DFI was found to be inversely correlated with the Ki-67 values. Univariate analysis was performed to identify the prognostic factors for OS after recurrence. The significant factors included tumor size, lymph node status, ER, PgR, DFI, recurrence site and Ki-67 index value. Among these factors, a multivariate analysis identified the Ki-67 index value in the primary tumor as an independent significant factor, particularly in luminal type tumors. The Ki-67 index value in the primary tumor was a significant prognostic factor for OS after disease recurrence. It is, therefore, important to take the Ki-67 index value into consideration for the treatment and follow-up of breast cancer patients.

Brief Fixation Does Not Affect Assessment of Hormone Receptor Expression in Invasive Breast Carcinoma Biopsies

In patients with invasive breast carcinoma, estrogen receptor α (ERα) and progesterone receptor (PR) expressions need to be assessed in core-needle biopsies (CNBs) before the start of neoadjuvant systemic treatment. Current guidelines recommend a minimum formalin fixation time of 6 hours. Considering the increasing demand for same-day diagnostics in oncology, more rapid tissue processing with shorter fixation times is required. To identify whether brief fixation (<6 h) of CNBs compared with conventionally fixed resection specimens provides for reliable immunohistochemical assessment of ERα and PR expression, 78 consecutive patients diagnosed with invasive breast carcinoma were included through the same-day diagnostics programme of the UMC Utrecht. Paraffin-embedded CNBs fixed for approximately 45 minutes were retrieved. Immunohistochemistry for ERα and PR was compared between the briefly fixed CNBs and conventionally fixed resection specimens. All slides were reviewed by means of consensus scoring by 2 blinded observers. Overall agreement between CNB and resections was 73/74 (98.6%) for ERα (κ=0.85; 95% confidence interval [CI]=0.56-1.00) and 69/75 (92.0%) for PR (κ=0.81; 95% CI=0.66-0.96). For ERα, positive and negative predictive values were 98.6% (95% CI=0.91-0.99) and 100.0% (95% CI=0.31-1.00), respectively. For PR, positive and negative predictive values were 100.0% (95% CI=0.91-1.00) and 76.0% (95% CI=0.54-0.90). In conclusion, analysis of hormone receptor expression in briefly fixed CNB seems comparable to results from conventionally fixed resection specimens of the same tumor.

Storage of Bovine Reproductive Tissues and RNA Extracts on Ice for 24 h or Repeated Freeze–Thaw Cycles do not Affect RNA Integrity

The aims of this study were to test (i) the effect of time of tissue and RNA extracts storage on ice and (ii) the effect of repeated freeze-thaw cycles on RNA integrity and gene expression of bovine reproductive tissues. Fragments of endometrium (ENDO), corpus luteum (CL) and ampulla (AMP) were subdivided and incubated for 0, 1, 3, 6, 12 or 24h on ice. RNA extracts were incubated on ice for 0, 3, 12 or 24h, or exposed to 1, 2, 4 or 6 freeze-thaw cycles. RNA integrity number (RIN) was estimated. Expression of progesterone receptor (PGR) and cyclophilin genes from RNA extracts stored on ice for 0 or 24h, and 1 or 6 freeze-thaw cycles was measured by qPCR. Tissue and RNA extract incubation on ice, and repeated freeze-thaw cycles did not affect RIN values of RNA from ENDO, CL or AMP. Storage on ice or exposure to freeze-thaw cycles did not affect Cq values for PGR or cyclophilin genes. In conclusion, neither generalized RNA degradation nor specific RNA degradation was affected by storage of tissue or RNA extracts on ice for up to 24h, or by up to 6 freeze-thaw cycles of RNA extracts obtained from bovine ENDO, CL and AMP.

Estrogen receptor negative/progesterone receptor positive breast cancer is not a reproducible subtype

IntroductionEstrogen receptor (ER) and progesterone receptor (PR) testing are performed in the evaluation of breast cancer. While the clinical utility of ER as a predictive biomarker to identify patients likely to benefit from hormonal therapy is well-established, the added value of PR is less well-defined. The primary goals of our study were to assess the distribution, inter-assay reproducibility, and prognostic significance of breast cancer subtypes defined by patterns of ER and PR expression.MethodsWe integrated gene expression microarray (GEM) and clinico-pathologic data from 20 published studies to determine the frequency (n = 4,111) and inter-assay reproducibility (n = 1,752) of ER/PR subtypes (ER+/PR+, ER+/PR-, ER-/PR-, ER-/PR+). To extend our findings, we utilized a cohort of patients from the Nurses’ Health Study (NHS) with ER/PR data recorded in the medical record and assessed on tissue microarrays (n = 2,011). In both datasets, we assessed the association of ER and PR expression with survival.ResultsIn a genome-wide analysis, progesterone receptor was among the least variable genes in ER- breast cancer. The ER-/PR+ subtype was rare (approximately 1 to 4%) and showed no significant reproducibility (Kappa = 0.02 and 0.06, in the GEM and NHS datasets, respectively). The vast majority of patients classified as ER-/PR+ in the medical record (97% and 94%, in the GEM and NHS datasets) were re-classified by a second method. In the GEM dataset (n = 2,731), progesterone receptor mRNA expression was associated with prognosis in ER+ breast cancer (adjusted P <0.001), but not in ER- breast cancer (adjusted P = 0.21). PR protein expression did not contribute significant prognostic information to multivariate models considering ER and other standard clinico-pathologic features in the GEM or NHS datasets.ConclusionER-/PR+ breast cancer is not a reproducible subtype. PR expression is not associated with prognosis in ER- breast cancer, and PR does not contribute significant independent prognostic information to multivariate models considering ER and other standard clinico-pathologic factors. Given that PR provides no clinically actionable information in ER+ breast cancer, these findings question the utility of routine PR testing in breast cancer.

Is OncotypeDX Recurrence Score (RS) of Prognostic Value Once HER2-Positive and. Low-ER Expression Patients are Removed?

Oncotype DX has been criticized for not providing significantly more prognostic information than histopathologic analysis. Oncotype DX was validated in cohorts that included poor prognostic factors (HER2-positive, low-estrogen receptor [ER] expression), raising the question: if patients with known high recurrence rates are excluded, is the Recurrence Score (RS) still valid? Our purpose was to determine if RS can be predicted with readily available measures. One hundred and twenty samples from August 2006 to November 2010 that underwent Oncotype DX testing were analyzed. Data included RS, ER, progesterone receptor (PR), HER2, and Ki67 status by immunohistochemistry (IHC). IHC data were used to create two linear regression models to predict RS. SAS's JMP-7 was used for statistical analysis. When comparing Oncotype DX- and IHC-derived ER and PR values, there were 21 discordant samples. The linear regression model PRS-F created with IHC data (ER, PR, HER2, Ki67) from all samples (n = 120) had an adjusted R(2) = 0.60 indicating a good model for predicting RS. The PRS-R model was built without low-ER and HER2-positive samples (n = 110). It had an adjusted R(2) = 0.38 indicating poor prediction of RS. Oncotype DX data showed good concordance with IHC for ER- and PR-expression in this cohort. Low-ER samples had high RS. After removing low-ER and HER2-positives, calculating RS with PRS-R from remaining data showed poor predictive power for RS (adjusted R(2) = 0.38). This result questions whether RS is prognostic in this subgroup (who would most benefit from further clarification of recurrence risk) and independent of pathology, or is simply producing random RS values. Data bases available to Genomic Health can resolve this issue.

The expression ratios of estrogen receptor α (ERα) to estrogen receptor β1 (ERβ1) and ERα to ERβ2 identify poor clinical outcome in endometrioid endometrial cancer

The prognostic relevance of estrogen (ER) and progesterone receptor (PR) expression in endometrioid endometrial cancer is still controversially discussed. The present study has focused on the evaluation of the prognostic value of ERα, ERβ1, ERβ2, and PR in this histotype. Specifically, we were interested in evaluating whether the relative level of ER subtype-specific expression (in terms of a ratio ERα/ERβ1 and ERα/ERβ2) would predict clinical outcome better than their absolute levels in patients with endometrioid endometrial cancer. To this end, protein content was assessed by immunohistochemistry in a group of 121 cases and staining was analyzed in relation to clinicopathologic variables, disease-free survival and overall survival. Results obtained have demonstrated that none of the biological markers analyzed possess an independent prognostic role with regard to disease-free survival. Multivariate analysis of overall survival has shown that ERα alone is not an independent prognostic indicator in patients with endometrioid endometrial cancer (hazard ratio [HR]; 0.5; 95% confidence interval [CI], 0.09-3.0; P = .5). On the other hand, an ERα/ERβ1 ratio of 1 or less or an ERα/ERβ2 ratio of 1 or less has proved to be independently associated with a higher risk of death (HR, 6.4 [95% CI, 1.0-40.6; P = .04] and 9.7 [95% CI, 1.1-85.3; P = .04], respectively) along with age, tumor stage, and Ki-67. In conclusion, we report here that the ERα/ERβ1 and ERα/ERβ2 expression ratios are independent prognostic markers of survival in endometrioid endometrial cancer; these findings suggest that phenotyping these interacting markers conjointly may better predict patient survival than each individual marker alone.

Abstract P6-07-38: The Value of Progesterone Receptor in Predicting the Recurrence Score for Hormone-Receptor–Positive Invasive Breast Cancer Patients

Abstract Background: Molecular genomic profiling currently plays a major role in treatment decisions for breast cancer patients. The 21-gene signature (Oncotype DX® [ODX]) is one of the most well-validated assays. Herein we evaluated the associations between high Recurrence Score (RS) measured by the ODX and pathological factors. Methods: From October 2007 to October 2010, the ODX assay was performed for 139 hormone-receptor–positive invasive breast cancer patients at single institution. Correlations between the RS and the following pathological factors were analyzed: tumor size (T), lymph node metastasis (N), nuclear atypia (NA), mitotic counts (MC), nuclear grade (NG), lymphatic and vascular invasion (LI and VI), estrogen receptor (ER), progesterone receptor (PgR), HER2, and Ki-67. Expression of ER, PgR, HER2, and Ki-67 was examined by immunohistochemistry. The Ki-67 labeling index was automatically counted with an Ariol-SL50 instrument (APPLIED IMAGING). The other pathological factors were estimated under the supervision of one experienced pathologist. Spearman rank correlation coefficients were calculated for the analyses. When the r was &amp;gt;0.4 or &amp;lt;–0.4 for two factors, they were determined to be well correlated. Results: Of 139 patients, the ODX assay revealed 68 (49%) low RS cases, 52 (37%) intermediate RS cases, and 19 (14%) high RS cases. Moderate positive or negative correlations were noted between the RS and PgR (r = −0.53), the RS and Ki-67 (r = 0.42), and the RS and NG (r = 0.41). No patients had high RS with PgR (3+) or NG1. The rate of high RS with Ki-67 (&amp;lt;20%) was one patient (2%). The number of cases who did not show PgR (3+) or NG1 or Ki-67 (&amp;lt;20%) was only 34 (25%). Among high RS cases, the correlation between PgR (0) and NG3 was 83%, the correlation between PgR (0) and NG2 was 75%, and the correlation between PgR (1+) and NG3 was 75%. The rate of high RS with PgR (0) and Ki-67 (≥20%) was 70%, that of PgR (1+) and Ki-67 (≥20%) was 58%, and that of PgR (2+) and Ki-67 (≥20%) was 21%. Correlations with T, N, NA, MC, LI, VI, ER, and HER2 were smaller (r ranging from −0.33 to 0.38). Conclusion: This study demonstrated that PgR, NG, and Ki-67 tend to be strongly correlated with the RS. Judging from PgR (3+), NG1, and Ki-67 (≥20%), we could select the patients who were proposed to perform the ODX. Among these factors, the correlation with PgR was particularly robust. PgR expression is a known marker of a functional ER and represents ER activity. In addition, the absence of PgR may reflect hyperactive cross-talk between ER and growth factor signaling pathways. We consider that these mechanisms could enhance the value of PgR in predicting the RS. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-07-38.

Abstract P1-07-13: Prognostic relevance of statistically standardized estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) in tamoxifen(TAM)-treated NCIC CTG MA.14 patients

Abstract Background: Poor inter-laboratory comparability of common clinically used breast cancer biomarkers led to a proposal of statistical standardization (SS) of laboratory results, similar to bone mineral density (BMD) z-scores. This analysis is the first utilization of SS in a trial where all women received TAM. Methods: MA.14 allocated 667 postmenopausal women to TAM +/− Octreotide LAR (OCT) based on locally determined ER/PR, without HER2 status. At 9.8 yrs median follow-up, the secondary endpoint of relapse-free survival (RFS) had a non-significant hazard ratio (HR) for TAM-OCT to TAM of 0.87 (95% CI 0.63–1.21; p = 0.40). 299 patients who were representative of MA.14 patients by treatment and stratification factors (exact Fisher p-values=0.19–0.90) had their tumors centrally assessed for ER, PR, and HER2 by RT-PCR. Continuous values were used for SS of each biomarker. Univariate (uni) assessment used similar categorizations as those for BMD, assigning ER/PR/HER2 values by number of standard deviations (SD) about the mean (Group 1, z-score ≥1.0 SD below mean; Group 2, z-score &amp;lt;1.0 SD below mean; Group 3, z-score ≤1.0 SD above mean; Group 4, z-score &amp;gt;1.0 SD above mean). A log-rank statistic was used to test for differences between SS biomarker groups with K-M plots for graphical description. Multivariate (multi) effects of SS biomarkers and baseline patient characteristics on RFS were examined with exploratory (un)stratified Cox step-wise forward regression, adding a factor if likelihood ratio criterion was p ≤ 0.05. Sensitivity analyses used a prior external HER2+ cut-point of ≥1.32 SD. Results: 292 patient samples passing internal analytical quality control were included in this analysis. Uni analyses indicated SS ER was not associated with RFS (p = 0.31). SS PR had a significant uni effect on RFS [p = 0.03; Group 4 compared to Group 1, HR of 0.33 (95% CI 0.12–0.90); Group 3 compared to Group 1, HR of 0.42 (95% CI 0.21–0.83); and Group 2 compared to Group 1 HR of 0.70 (95%CI 0.36–1.37)]. SS HER2 also had a significant uni effect on RFS [p = 0.004; Group 4 compared to Group 1, HR of 0.90 (95% CI 0.37–2.16)]; Group 3 compared to Group 1, HR of 0.39 (95% CI 0.18–0.84); and, Group 2 compared to Group 1, HR of 0.34 (95% CI 0.16–0.70)]. Multi stratified/unstratified Cox models indicated T1 tumours (p = 0.02/p = 0.0002) and higher SS PR (p = 0.02/0.01) were associated with significantly longer RFS; other unstratified results showed that N-ve patients had better RFS (p &amp;lt; .0001), while local ER/PR status did not impact RFS (p &amp;gt; 0.05). The HER2+ cut-point of ≥1.32 SD indicated directionally worse RFS (uni p-value=0.05; multi p-value=0.06). Discussion: In MA.14, all women received TAM. Local ER/PR status using categorical or semi-quantitative values did not impact RFS. A statistically standardized approach using continuous centralized ER, PR, HER2 by RT-PCR demonstrated that increasing PR values were associated with better RFS. Evaluation in other trials may provide support for this methodology. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-07-13.

Comparison of the oestrogen and progesterone receptor status in primary breast carcinomas as evaluated by immunohistochemistry and immunocytochemistry: a consecutive series of 267 patients

The use of cytological specimens to evaluate tumour biomarkers in metastatic breast cancer lesions has attracted increased interest because of the considerable number of reports that have shown discordance between the primary tumour and metastatic lesion. Oestrogen receptor (ER) and progesterone receptor (PgR) assays are crucial for the management of patients with breast cancer, in both adjuvant and palliative settings. The aim of this study was to compare the ER and PgR immunocytochemical analysis of fine needle aspiration (FNA) samples with the immunohistochemistry (IHC) of surgical specimens and core biopsies from primary breast cancers. The FNA specimens were prepared as cell blocks (n = 25) or ThinPreps (n = 258) for the immunocytochemistry (IC) ER and PgR analyses. Sixteen patients were excluded because of lack of follow-up (n = 1), neoadjuvant therapy (n = 3) or cell counts in their fine needle aspirates that were too low (n = 12). The results of IC on 25 cell blocks and 242 ThinPreps were compared with IHC on the corresponding core needle biopsies (n = 16) or excised tumours (n = 251). The ER and PgR status was defined as negative (when less than 10% of the nuclei were stained) or positive (when equal or more than 10% of the nuclei were stained). Kappa statistics were used to evaluate the concordance. The ER concordance was 98% with ThinPrep (κ = 0.93) and 92% with cell block (κ = 0.82). The corresponding values for PgR were 96% (κ = 0.91) and 96% (κ = 0.92). Our results confirm that, in cases in which biopsies or surgical specimens are not available, IC (with either cell block or ThinPrep techniques) is a reliable method for the determination of the ER and PgR status performed under strict conditions using primary breast carcinomas, and is therefore potentially useful in metastatic settings.

Assessment accuracy of core needle biopsy for hormone receptors in breast cancer: a meta-analysis

The concordance of hormone receptors (HR) status identified by core needle biopsy (CNB) compared with excisional biopsy (EB) has been widely reported, but results were extremely variable and underpowered. To derive a more precise estimation of assessment accuracy of CNB for HR in breast cancer, we conducted a meta-analysis of all eligible studies comparing concordance or disconcordance between CNB and EB for HR status. Eligible articles were identified by search of databases including PubMed, Web of Science, EMBASE, and Chinese Biomedical Literature database for the period up to November 2011, and the reference lists of identified studies, relevant reviews, meta-analyses, and abstracts from recent conference proceedings were reviewed as a augmented searching. Finally, a total of 21 articles involving 2,450 patients for estrogen receptor (ER) and 2,448 patients for progesterone receptor (PR) were included and analyzed in this analysis. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies checklist. The overall aggrement between CNB and EB were 92.8 % for ER (κ = 0.78) and 85.2 % for PR (κ = 0.66), indicating a good agreement in PR and a better result in ER. The pooled sensitivity and specificity were 97.3 % (95 % CI 96.0-98.2) and 82.0 % (95 % CI 68.2-90.6) for ER, and the corresponding values for PR were 92.3 % (95 % CI 88.2-95.1) and 76.5 % (95 % CI 64.6-85.3), respectively. The pooled positive likelihood ratios was 5.39 % (95 % CI 2.92-9.97) and the negative likelihood ratios was 0.03 % (95 % CI 0.02-0.05) for ER, the corresponding values for PR were 3.93 % (95 % CI 2.53-6.11) and 0.10 % (95 % CI 0.07-0.16), respectively. In summary, although a good agreement was observed between CNB and EB for both ER and PR, we still suggest that negative HR testing results should be interpreted with caution or repeated on EB.

Diagnostic value of progesterone receptor and p53 expression in uterine smooth muscle tumors

BackgroundThe diagnosis of uterine smooth muscle tumors depends on a combination of microscopic features. However, a small number of these tumors still pose difficult diagnostic challenges.AimTo investigate progesterone receptor (PR) and p53 expression in leiomyomas (LMs), atypical leiomyomas (ALMs), smooth muscle tumors of uncertain malignant potential (STUMP), and leiomyosarcomas (LMSs) and to evaluate the potential utility of the selected immunohistochemical markers in differentiating these tumors.Materials and methodsImmunohistochemical expression of PR and p53 was investigated in 41 uterine smooth muscle tumors comprising: 15 LMS, 4 STUMP, 6 ALM and 16 LM. Quantitative evaluation of PR and p53 expression was graded on a scale from 0 to 3+.ResultsLeiomyosarcomas showed reduced PR expression. All LMs as well as ALMs and STUMP were stained intensely for PR. Conversely, LMS was strongly stained with p53, while the three non-sarcomatous groups (STUMP, ALM, LM) were either entirely negative or weakly stained for p53. Regarding both PR and p53 expression, the difference between the LMS group and the three non-sarcomatous groups was highly significant (p < 0.001). Combined high PR - low p53 expression was seen in all the 26 examined cases of the non-sarcomatous group including the STUMP cases and none of the LMS cases. Therefore, it represents a "benign" profile with 100% specificity in diagnosis of a non-sarcomatous tumor.ConclusionImmunohistochemistry for PR and p53 is valuable as an adjunct tool to morphological assessment of problematic uterine smooth muscle tumors.

P5-11-11: Automated Quantification Methods Improve the Accuracy of PR as an Independent Prognostic Factor in Tamoxifen Treated Breast Cancer Patients.

Abstract Background Adjuvant endocrine therapy reduces the risk of recurrence and death in hormone receptor positive breast cancer patients. However, 40–50% of estrogen receptor (ER) positive tumors are resistant to endocrine therapy. We have previously shown that quantitative measurement of ER protein expression has limited value as a prognostic marker in tamoxifen treated patients. The presence of progesterone receptor (PR) expression has shown promise as prognostic and/or predictive marker for endocrine therapy, including adjuvant tamoxifen, but reports are contradictory. Automation of scoring methods will improve the accuracy of PR scoring and its value as a prognostic factor. Methods: This retrospective study evaluated breast cancer patients treated with adjuvant tamoxifen (n=458) from 1985–2000 at the Tom Baker Cancer Centre, Calgary, Canada. Tissue microarrays were assembled from formalin fixed paraffin embedded tumor tissue. Clinico-pathologic data was obtained from chart review. Five-year disease-free survival (DFS) was the primary outcome. DAB-based PR staining was used to generate Allred PR scores, as well as to generate scores for PR percent area expression and PR integrated optical density (PR IOD) using the DAKO ACIS III scanner and image analysis software. PR tumor nuclear pixel intensity density scores were obtained using fluorescence-based PR staining, scanned and quantified with a HistoRx PM2000 scanner andAQUA image analysis software. Continuous variables were dichotomized using Xtile. Results: In our tamoxifen cohort, 5-year DFS was associated with tumor grade [HR 4.9(3.5−6.9), p&amp;lt;0.001], tumor size [HR 2.7(1.9−3.8), p&amp;lt;0.001], lymph node status [HR 5.7(4.0−8.0), p&amp;lt;0.001] and ER status [HR 2.4(1.3−4.7), p=0.008]. Low PR was associated with significantly worse DFS regardless of the method used to quantify its expression. Methods of analysis requiring less subjective input had stronger associations between PR expression and outcome. The subjective identification of tumor and subjective biomarker quantification used in Allred scoring [HR 2.2(1.4−3.3), p&amp;lt;0.001] was less effective than ACIS scoring [PR percent area: HR 2.8(1.8−4.3), p&amp;lt;0.001; PR IOD: HR 2.9(1.9−4.6), p&amp;lt;0.001], which only requires subjective identification of the tumor. All methods were inferior to fluorescence-based AQUA scoring [HR 4.2(2.7−6.5), p&amp;lt;0.001], which automatically detects the tumor nuclear area using pan-cytokeratin and DAPI staining and measures the PR expression within this compartment. Multivariate analysis, which included age, tumor size, tumor grade, lymph node status, and ER status, confirmed that AQUA [HR 3.3(2.0−5.6), p&amp;lt;0.001] was superior to ACIS PR percent area [HR 2.3(1.4−3.9), p=0.002] and ACIS PR IOD [HR 2.7(1.6−4.8), p&amp;lt;0.001], all of which were superior to Allred scoring [HR 1.2(0.7−2.1), p=0.511]. Conclusions: We conclude that: 1) PR is an independent prognostic marker in our cohort, 2) using less subjective, automated quantitative scoring methods improves the value of PR as a prognostic biomarker, 3) AQUA appears superior to other automated methods and that 4) the incorporation of digital image analysis into practice would improve the prognostic value of PR expression in the clinical setting. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-11-11.

P5-13-19: Borderline Estrogen and Progesterone Receptor Expression and Efficacy of Anti-Estrogen Therapy Analyzed by Subpopulation Treatment Effect Pattern Plot Analysis.

Abstract Background: The American Society of Clinical Oncology (ASCO) and the College of American Pathologists (CAP) recently recommended that estrogen receptor (ER) and progesterone receptor (PR) values be considered positive in the evaluation of breast cancer specimens if there are at least 1% positive tumor nuclei by immunohistochemisty (IHC) scoring. This change constitutes a lower cutoff value than the 5% or 10% widely used in the past and increases the number of patients that can now be treated with anti-estrogen therapy, a therapy which carries significant treatment efficacy and a favorable toxicity profile. Despite the new recommendation however, it remains unclear if patients whose tumors display borderline ER and/or PR expression truly benefit from anti-estrogen therapy. Methods: We examined a total of 608 patient samples from the OHSU Knight Cancer Institute Breast Cancer Tissue Repository for which we have quantitative ER and PR information and their clinical outcome. Of those, 282 patients did not receive any systemic treatment and 165 received anti-estrogen therapy (the majority tamoxifen). Cytosolic steroid hormone receptors were quantitated by conventional steroid binding assay and Scatchard plot analysis or by enzyme-linked immunoassay system. For immunoassays, human estrogen receptor (ER) and progesterone receptor (PR) kits were obtained from Abbott Laboratories and assays were conducted according to manufacturer's specification. We performed subpopulation treatment effect pattern plot (STEPP) analysis to explore the presence of interaction between treatment effects and quantitative ER and PR levels. Clinical outcome used in this study includes 5-year overall survival and 5-year breast cancer free interval. Results: Multi-variate analysis finds neither ER nor PR expression adjusted by treatment status is associated with either overall survival (P= 0.20, median follow up of 63 months) or breast cancer free interval (P= 0.82, median follow up of 60 months). For both ER and PR, there is no interaction between treatment outcome (5 year survival probability) and levels of hormone receptor expression based on Kaplan-Meier estimate (P=0.36 and P= 0.65, respectively). Patients with borderline ER expression appear to benefit from anti-estrogen therapy while patients with borderline PR expression appear to have worse outcome with anti-estrogen therapy. Conclusions: Though descriptive in nature, our STEPP analysis provides support for the recommendation by ASCO and CAP to lower the cutoff for ER positivity in breast cancer specimens. There is overall no interaction between the level of hormone receptor and treatment benefit for all patients from low ER to high ER. Therefore, treatment will benefit all patients including those with low ER levels. Extending hormone therapies to the group of patients whose tumors express borderline PR values, however does not seem to confer therapeutic benefit. More study is needed to determine the benefits of offering anti-estrogen therapy to patients whose tumors express low PR. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-13-19.

Branched-chain Assay for ER, PR, and HER2 RNA Levels is a Useful Adjunct in the Evaluation of ER, PR, and HER2 in Breast Cancer

Purpose: The status of estrogen receptor (ER), progesterone receptor (PR) and HER2 is critical in patients undergoing breast cancer treatment. We performed this study to evaluate the QuantiGene Reagent System as a clinical test for detecting ER, PR, and HER2 RNA levels in formalinfixed, paraffin-embedded (FFPE) tissue. Methods: The RNA levels of ER, PR and HER2 were measured using the QuantiGene2.0 assay in FFPE tissue from breast cancer patients (n=40) and compared with ER and PR immunohistochemistry results and HER2 fluorescence in situ bybridization (FISH) results. Results: When the cut-off values for ER, PR, and HER2 RNA levels were 5.0, 7.2, and 50, respectively, the sensitivity, specificity, and positive and negative predictive value of the QuantiGene 2.0 Assay were 96.6%, 90%, 96.7%, and 90%, for ER; 89.7%, 81.8%, 92.9%, and 75% for PR; and 83.3%, 96.4%, 90.9%, and 93.1% for HER2, respectively. The Allred scores for ER and PR as well as the HER2 FISH ratio were correlated with RNA levels (p=0.046, r=0.32; p<0.001, r=0.61; p<0.001, r=0.75, respectively). Conclusion: We demonstrated that the ER, PR, and HER2 RNA levels as measured by the QuantiGene 2.0 assay were reproducible and correlated well with immunohistochemistry and FISH results. Measuring ER, PR, and HER2 RNA levels from formalin-fixed, paraffin-embedded tissue using the QuantiGene 2.0 assay, which was a relatively simple technique easily performed in a usual laboratory, appeared to a helpful adjunct in determining the status of ER, PR, and HER2 in breast cancer.

QuantiGene 2.0 Assay for ER, PR and HER2 RNA Levels Is a Useful Adjunctive for the Evaluation of ER, PR and HER2 in Breast Cancer.

Abstract Immunohistochemistry (IHC) for the estrogen receptor (ER) and progesterone receptor (PR) is an established procedure in the routine treatment of patients with breast cancer, primarily to predict responses to hormonal therapy. HER2 IHC and FISH are also recommended to select patients for anti-HER2 based therapy. The IHC method for ER and PR is semi-quantitative and needs standardization. Furthermore, ER and PR RNA levels are continuous variables and quantitative measurement of ER levels can help predict the tamoxifen benefit breast cancer. In this study, the RNA levels of ER, PR and HER2 were measured using the QuantiGene 2.0 assay in formalin-fixed, paraffin- embedded (FFPE) tissue samples from breast cancer (n=40) and compared with conventional ER/PR IHC results and HER2 FISH results. There were no cases of discrepancy in ER status between staining with the SP1 antibody and staining with the 6F11 antibody; however, the ER score was statistically different between them (5.3 ± 3.3 vs. 4.9±3.2, P=0.02). One out of 40 cases (2.5%) showed a false negative result when performed using a 2mm representative tissue sample (TMA), and 1 out of 40 cases (2.5%) showed a discrepant ER status between the results using the Allred scoring system and the fractional scoring system. These results reconfirmed that various factors such as the primary antibodies used, interpretation methods and TMA vs. whole section, influence the results of IHC. When the cut-off values for ER, PR and HER2 RNA levels were 5.0, 7.2 and 50, respectively, the sensitivity, specificity, positive predictive value and negative predictive value of the QuantiGene 2.0 Assay were 96.6%, 90%, 96.7% and 90%, respectively, for ER; 89.7%, 81.8%, 92.9% and 75% for PR, and 83.3%, 96.4%, 90.9% and 93.1% for HER2. The Allred scores for ER and PR were correlated with RNA levels (P=0.046, R=0.32; P=0.00, R=0.61, respectively), and the HER2 FISH ratio was correlated with RNA levels (P=0.00, R=0.76). In conclusion, measuring ER, PR and HER2 RNA levels, which is known to have additional benefits in patient treatment, from FFPE tissue may be a helpful adjunctive in determining the status of ER, PR and HER2 in breast cancer. And the QuantiGene 2.0 assay, which does not require an RNA extraction step, uses FFPE samples, and expensive modern equipment, is easy to perform even in a small scale laboratory. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4153.

Progesterone receptor is a significant factor associated with clinical outcomes and effect of adjuvant tamoxifen therapy in breast cancer patients

Estrogen receptor status in breast cancer is associated with response to hormonal therapy and clinical outcome. The additional value of progesterone receptor (PR) has remained controversial. We examine the value of PR for prognosis and response to tamoxifen on a population-based series of 4,046 invasive early stage breast cancer patients. Clinical information for age at diagnosis, stage, pathology, treatment and outcome was assembled for the study cohort; the median follow-up was 12.4 years. PR status was determined by immunohistochemistry using a rabbit monoclonal antibody on tissue microarrays built from breast tumor surgical excisions. Survival analyses, Kaplan-Meier functions and Cox proportional hazards regression models were applied to assess the associations between PR and breast cancer specific survival. Progesterone receptor was positive in 51% of all cases and 67% of estrogen receptor positive (ER+) cases. Survival analyses for both the whole cohort and ER+ cases given tamoxifen therapy showed that patients with PR+ tumors had 24% higher relative probability for breast cancer specific survival as compared to PR- patients, adjusted for ER, HER2, age at diagnosis, grade, tumor size, lymph node status and lymphovascular invasion covariates. Higher PR expression showed stronger association with patient survival. Log-likelihood ratio tests of multivariate Cox proportional hazards regression models demonstrated that PR was an independent statistically significant factor for breast cancer specific survival in both the whole cohort and among ER+ cases treated with tamoxifen. PR adds significant prognostic value in breast cancer beyond that obtained with estrogen receptor alone.

Value of Intraoperative Examination of Axillary Sentinel Nodes in Carcinoma of the Breast

The value of frozen sections in the intraoperative examination of sentinel nodes (SN) remains controversial. Accurate frozen sections will spare those patients with node metastasis from a second procedure to complete the axillary dissection. We examined our own experience with intraoperative examination of SN. Between January 1, 2006, and December 31, 2006, we performed 236 sentinel lymph node biopsy procedures that were read as "frozen-section-negative." An additional 47 sentinel lymph node biopsy patients were frozen-section-positive for metastatic disease and underwent immediate completion axillary dissection. At least 1 SN was found in all 283 women (100%). The number of patients with false-negative frozen sections was tallied; patient data were reviewed for a number of variables to see which factors might be associated with a false-negative result. Eleven patients had positive nodes on subsequent examination of the formalin-fixed, hematoxylin and eosin-stained slides; the false-negative rate of intraoperative frozen section was 4.7%. The sensitivity of the negative frozen section was > 95%. The following variables were compared for significance: pathologist, nuclear grade, histologic grade, margins, lymphovascular invasion, tumor type (ductal versus lobular), and estrogen receptor and progesterone receptor values. The only significant variables were lymphovascular invasion (p = 0.019) and presence of in situ ductal carcinoma (p = 0.001). Our data confirm the value of intraoperative examination of SN: > 95% sensitivity. Presence of in situ ductal carcinoma or lymphovascular invasion makes these tumors more likely than others to have micrometastases to SN overlooked.

The predictive value of PgR and HER-2 for response to primary systemic chemotherapy in inflammatory breast cancer

Inflammatory breast cancer (IBC) is the most aggressive form of primary breast cancer. We examined the relationship between clinicopathological factors and clinical response to primary systemic chemotherapy (PSC) and outcome. Twenty-five patients with IBC were examined. Twelve patients received an anthracycline-based regimen, and 13 patients received an anthracycline-and a taxane-containing regimen as PSC. The expression of hormone receptors and human epidermal growth factor receptor-2 (HER-2) was determined by immunohistochemistry. The overall clinical response rate was 64.0%. Clinical response to PSC was higher in patients with progesterone receptor (PgR)-positive (P = 0.01) and HER-2-negative (P = 0.03) tumors. Patients with fewer than ten involved axillary lymph nodes (P = 0.01 and P = 0.02, respectively) and with a clinical response to PSC (P = 0.02 and P = 0.01, respectively) showed better distant disease-free survival and overall survival. In patients with IBC, PgR-positive and HER-2-negative tumors are more sensitive to anthracycline-based PSC. Patients with extensive residual tumor (ten or more lymph-nodes involved, no response to PSC) after PSC had unfavorable prognoses.