|Year : 2013 | Volume
| Issue : 1 | Page : 44-49
Morphological profile and receptor status in breast carcinoma: An institutional study
Chandrika Rao, Jayaprakash Shetty, HL Kishan Prasad
Department of Pathology, K S Hegde Medical Academy, Deralakatte, Mangalore, Karnataka, India
|Date of Web Publication||10-Apr-2013|
Department of Pathology, K S Hegde Medical Academy, Deralakatte, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Context: The data on histological and receptor status in breast cancer in an Indian population is limited as receptor status is not routinely carried out for these patients. In the present study, receptor status was analyzed and it was correlated with morphological prognostic parameters.
Objective: To analyze the morphological prognostic parameters and its correlation with receptor status in Indian women.
Design: The sample consisted of 126 specimens of invasive breast cancer received in department of pathology of our institution with teaching hospital attached to it, situated in South Canara district of, Karnataka, South India between year 2009 and 2011.
Result: Sixty-seven percent of patients were 50 years or younger. Histological types were invasive ductal carcinoma, not otherwise specified (58.7%), and overall (15.9%) were grade 3. Estrogen receptor was positive in 36.5%, HER/neu was overexpressed in only three cases; 50.0% were "triple" negative (estrogen receptor, progesterone receptor, HER/neu negative). Estrogen receptor (ER) and progesterone receptor (PR) positivity decreased with increase in tumor grade. There was significant association between tumor size and ER positivity.
Conclusions: Breast carcinoma in our population presents at younger age than Western population. Our results showed very high proportion of triple-negative breast cancers. The tumor size and grade is related to expression of only ER. The findings suggest that women in our population more often have histologically aggressive breast carcinoma at young age, likely to be less susceptible to conventional hormonal and targeted antibody treatment. Detecting and treating this increasing important cause of mortality will be an enormous challenge.
Keywords: Breast cancer, estrogen receptor, HER-2/neu, progesterone receptor
|How to cite this article:|
Rao C, Shetty J, Kishan Prasad H L. Morphological profile and receptor status in breast carcinoma: An institutional study. J Can Res Ther 2013;9:44-9
|How to cite this URL:|
Rao C, Shetty J, Kishan Prasad H L. Morphological profile and receptor status in breast carcinoma: An institutional study. J Can Res Ther [serial online] 2013 [cited 2020 May 28];9:44-9. Available from: http://www.cancerjournal.net/text.asp?2013/9/1/44/110358
| > Introduction|| |
Breast cancer is a leading cause of death in women.  It is an important health issue not only in the developed world but also in resource limited nations.  Incidence of breast cancer is low in India compared to western countries, but it is associated with poor prognosis and high mortality, may be due to late presentation at advanced stages.  In India, cancer of breast is the most common cancer among women in many regions and has overtaken cervical cancer, which was the most frequent cancer a decade ago , perhaps due to changes in lifestyle and western influences. 
There are numerous risk factors for breast cancer. Important risk factors are age, age at menarche/menopause, parity, duration of breast-feeding, changes in breast, genetic, nutritional, environmental and hormone factors. Despite breast cancer risk factors being known, in 50% of women the risk factors are not detected.  Five to ten percent of breast cancers are due to genetic mutation in BRCA-1 and BRCA-2. Breast cancer is a hormone dependant tumor prototype and one-third of patients respond to endocrine therapy . Human epidermal receptor-2/neu (HER-2/neu) gene amplification occurs in 20-30% of breast cancers and it is associated with poor prognosis, lower response to hormone therapy and chemotherapy. HER-2/neu positive breast cancer predicts response to anti-HER-2/neu antibody. 
Immunohistochemistry is primarily a research tool in our population. Hormone receptors and HER-2/neu study are not routinely measured as it is expensive. This could impact treatment decisions and patients are sometimes treated empirically with tamoxifen.
The present study was planned keeping in mind predictive importance of receptor status for the prognosis of illness and application of appropriate therapy. The objective was to determine receptor status and it's correlation with other morphological prognostic parameters including age in an Indian population.
| > Materials and Methods|| |
The sample consisted of one hundred twenty six specimens of invasive breast cancer received in department of pathology of our institution with teaching hospital attached to it. Study included primary operable consecutive prospective cases. This study excluded breast biopsies, lumpectomies, cell block and neoadjuvant treated cases.
The study was approved by institutional ethical committee. A voluntary informed consent was taken from all the patients.
Expression of estrogen receptor(ER), progesterone receptor (PR) and HER-2/neu were analysed in specimens of invasive breast cancer tissue received in the form of modified radical mastectomy.
After formalin fixation, paraffin embedding and staining with hematoxylin and eosin, histopathological features were determined, prior to immunohistochemical examination. Histopathological grade was assessed using Bloom Richardson method, modified by Elston and Ellis. 
Tumor tissue was routinely fixed overnight (12 hrs) in 10% buffered formalin. Representative sections were taken next day, processed and embedded. Four-micrometer thickness sections were, mounted onto silane -coated slides and left to dry overnight at 37˚C. They were then deparaffinized, rehydrated and underwent antigen retrieval (citrate buffer, pH 7.1) by microwaving for 20 minutes, HER - 2/neu for 4 minutes. After cooling down to room temperature, the sections were incubated for 20minutes with 3% hydrogen peroxide to block any endogenous peroxidase activity, washed with TRIS buffer (TBS), and incubated with (power block) for 15minutes to block any nonspecific staining. They were then washed with TBS, and incubated with primary antibodies (ER clone ID5, PR clone PR88 and HER2 clone EP1045Y, BioGenex) for 1 hour to identify tumor markers by antigen antibody reaction. The sections were then washed with TBS, and incubated with secondary link antibody (super sensitive poly-HRP) for 30 minutes. Finally the sections were washed with TBS and incubated for 10 minutes with DAB chromogen contrasted with hematoxylin counterstain. External positive and negative control slides were used in each staining. Normal breast tissue used as positive internal control for ER and PR.
ER or PR was considered positive if finding of more than 1% tumor cell nuclei are immunoreactive. Negative for ER or PR if finding of less than 1% of tumor cell nuclei are immunoreactive  [Figure 1]a, c.
|Figure 1: Immunohistochemical staining. (a) Nuclear staining of ER (original magnification x10). (c) Nuclear staining of PR (original magnification x10). (b and d) Membrane staining of HER-2/neu (original magnification x10 and x40)|
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HER-2/neu status was assessed by a score that includes the intensity and the percentage of positive tumor cells. HER2 testing results fall into three categories; positive, equivocal and negative  [Table 1] and [Figure 1]b, d. For the purpose of this study equivocal results were considered negative.
The data were entered and analyzed in SPSS .Frequencies and percentages all the variables were computed. The Chi-square (χ2 ) test was used to compare the association of expression of ER, PR and HER-2/neu and the macroscopic and microscopic characteristics of the tumors. The results were considered statistically significant if the P-value was <0.05.
| > Results|| |
There were 126 cases of microscopically confirmed invasive breast carcinoma in women. Most women (59 of 126; 46.8%) were between age group of 41 and 50 years. Twenty-six (20.6%) were 40 years and younger at diagnosis [Table 2].
Most (75 of 126; 58.7%) were invasive ductal carcinoma, not otherwise specified (IDC NOS). [Figure 2]a There were other subtypes of invasive carcinoma, including (19 of 126; 15.1%) of invasive lobular carcinoma(ILC), [Figure 2]c, ten mixed (IDC NOS + ILC), 7 each of pleomorphic lobular carcinoma and medullary carcinoma [Figure 2]b, d including a case of bilateral medullary carcinoma. Mucinous carcinoma (4 cases) [Figure 3]a, invasive papillary carcinoma (3 cases) [Figure 3]c and tubular carcinoma (1 case) [Figure 3]b, d [Table 3].
|Figure 2: Histological types of invasive breast carcinoma. (a) Invasive ductal carcinoma, not otherwise specified (H and E, original magnification ×20). (c) Infiltrating lobular carcinoma (H and E, original magnification ×20). (b and d) Medullary carcinoma (H and E, original magnification ×20)|
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|Figure 3: Histological types of invasive breast carcinoma. (a) Mucinous carcinoma (H and E, original magnification × 20). (c) Infiltrating papillary carcinoma (H and E, original magnification ×20). (b and d) Tubular carcinoma (H and E, original magnification ×20 and ×40)|
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Majority of our patients (101 of 126; 80.2%) had tumor size lesser than 5 cm. There was significant association between tumor size and estrogen receptor (ER) positivity (P < 0.05) [Table 4].
Overall (56 of 126; 44.4%) were histological grade I, 39.7% grade II, 15.9% grade III. ER and PR positivity decreased with increase in tumor grade (P<0.05) [Table 4].
Forty-seven percent of our patients showed significant content of ductal carcinoma in situ. 36 of 126 (28.6%) of invasive carcinoma showed focal necrosis of which only 14 were ER positive. 21.4% showed comedo necrosis. No significant association observed between necrosis and estrogen and progesterone receptor status. There was noticeable relation between necrosis and HER-2/neu receptor status (P < 0.05).
Sixty-six of 126 cases (52.4%) were node negative. 28.6% cases presented with axillary lymph node metastasis in 1-3 lymph nodes and 19% in 4- 9 lymph nodes. The presence or absence of metastatic nodes did not correlate significantly with ER, PR status.
Lymphovascular invasion was noted in 19.8% of all tumors. No significant association noted between ER, PR, HER-2/neu and lymphovascular invasion.
Elastosis is presence of focal deposits of elastic tissue in abnormal amounts and was seen in 15.9% of our patients. Seven and eight with elastosis, tended to be ER and PR positive, whereas 30 and 33 of tumors without elastosis were ER and PR positive, respectively. Significant association was noted between HER-2/neu receptor positivity and stromal elastosis. (P < 0.05)
Desmoplasia is extensive stromal fibrosis and was observed in 30.2% of invasive breast carcinoma. Eight and 11 with desmoplasia were ER and PR positive.
Estrogen receptor studies showed that overall ER was positive in 36.5%, PR in 31.7% and HER-2/neu in only 2.4% cases [Table 5]. IDC NOS type, 21 of 126 and 23 of 126 were ER and PR positive, respectively. HER-2/neu overexpression was identified in only three cases, all of which were IDC NOS [Table 3]. A large proportion of tumors 63 of 126 (50.0%) were triple negative [Table 6].
| > Discussion|| |
It is well known that breast cancer prognosis depends on various clinicopathological factors including metastatic status of lymph nodes, tumor size, tumor grade, hormone receptor status and HER-2 status. 
The current trend in analyzing the clinical outcome of a patient with breast cancer is to examine predictive and prognostic factors related to the patient and tumor. Predictive factor is related to degree to which the patient could respond to specific therapy, while prognostic factor is related to metastatic potential of the tumor. Several studies have been reported related to examination of prognostic and predictive factors in breast cancer. ,,,,,,,,,,,,,,, With advancement in science and technology, new molecular methods are giving insight into biology of breast cancer and opening avenues for developing therapeutic strategies and predict the outcome.  In literature, HER-2/neu receptor overexpression is found to be an independent poor prognostic of tumor grade, tumor size and lymph node status.  In this study, we conducted comprehensive analysis of breast carcinomas taken from 126 patients.
The Early Breast Cancer Trialists Collaborative Group has confirmed that the amount of benefit from adjuvant endocrine therapy in breast cancer is proportional to the amount of ER present in the primary tumor. The option of hormone therapy is now offered to every patient of breast cancer irrespective of age based on tumor receptor status. 
The prevalence of ER, PR and HER-2/neu expression were 36.5%, 31.7% and 2.4%, respectively [Table 4]. Earlier studies have reported a higher incidence of receptor expressions. ,, This results are nearly similar to previous studies in India.  indicating that the cause for the low receptor expression in Indian patients may be due to racial and geographic differences younger age and higher grade of breast cancers. Discordant findings in the study may be attributed to the race, as earlier reports were based on western population.  The proportion of breast carcinoma with HER2/neu overexpression is very low (2.4%), although not statistically significant, compared to 10 - 34% HER2/neu positive breast carcinomas as reported earlier.  Thus the more aggressive breast carcinomas as reported do not appear to be due to HER2/neu overexpression.
In contrast to what is commonly known incidence of breast cancer with age, our results showed that 67.4% of the patients were young with age less than 50 years. Majority of them (46.8%) were between the ages of 41 and 50 years. This age distribution is significantly younger than what is currently seen in Western countries.  In our study , we did not find any significant association between the age of the patients and their tumor expression of ER, PR and HER-2/neu. We found that patients with ER and PR negative tumors were mostly young (41-50 years) similar to results obtained by Farid Saleh and Saud Abdeen.  Primary breast carcinoma arising before 40 years age are far more aggressive and likelier to metastasize and reduce patients survival than arising in older patients, regardless of hormone receptor status.  In this study association of HER-2/neu with age showed that only three were positive for HER-2/neu expression, and all three cases of were less than 40-year-old. This is similar to what is reported in literature that HER-2/neu over expression declines with age. , HER2 amplified breast cancers have unique biological and clinical characterisatics. They have increased sensitivity to certain cytotoxic agents such as doxorubin, relative resistance to hormone agents and propensity to metastasizes to the brain and viscera. These tumors have higher proliferation rates and are associated with poorer patient prognosis. The poor outcome is dramatically improved with appropriate chemotherapy combined with the HER2 targeting drug trastuzumab. 
Receptor positive tumors were smaller in size as compared to receptor negative tumors at the time of presentation. Similar to results obtained by Dutta et al were the receptor status was noted to be comparatively increased in tumor size less than 5cm. We found significant association between tumor size and ER status (P < 0.05) [Table 4].
Most common histological subtype was invasive ductal carcinoma, not otherwise specified and invasive lobular carcinoma. This confirms WHO classification of invasive breast carcinomas in relation to percentage occurrence of these subtypes.  In our study breast carcinomas with ER and PR expression were found to be greater in lobular than in ductal tumors, similar to results obtained by Jalava et al.  There was lack of significant association between histological subtypes and receptor status. This correlated with study conducted by Kommnass et al. 
Overall 15.9% of the carcinomas were grade 3. There was significant inverse correlation (p < 0.05) between tumor grade and ER status. Results in the study of histological grades of tumors and receptor status are in agreement with reports of earlier studies which have shown that poorly differentiated tumors are more common in receptor negative patients.  Similarly we found significant correlation between necrosis and HER-2/neu overexpression (P < 0.05).
Lymph node involvement is an important prognostic factor. Positive lymph nodes is associated with worst outcome. Totally 57.6% cases were lymph node positive. There was no statistical significant correlation between receptor expression and lymph node involvement.
Triple- negative breast carcinoma is recently recognized type of breast carcinoma with poor prognosis.  In our study there was greater proportion of the triple-negative breast carcinoma (50%), compared to diifferent studies published [Table 7]. The term "basal" type of carcinoma is sometimes used interchangeably with triple-negative carcinoma, having adverse pathobiological features and poor prognosis. , This suggests that women in our population have excess of the triple negative, basal phenotype of poor prognosis breast carcinoma. The poor prognosis was thought to reflect the advanced stage at diagnosis rather than intrinsic biologic factors.
|Table 7: Proportion of Estrogen receptor, HER2/neu status and Triple negative breast cancers among different studies|
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In conclusion, the prevalence of ER, PR and HER2/neu overexpression among Indian patients does not fall within the ranges given in literature. The tumor size and grade is related to expression of only ER. Our results showed very high proportion of triple-negative breast cancers. The findings suggest that South Indian women in the South Canara district, more often have genetically driven, histologically aggressive breast carcinoma at young age, likely to be less susceptible to conventional hormonal and targeted antibody treatment. Detecting and treating this increasing important cause of mortality will be an enormous challenge.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]