Estrogen receptor protein (ERP) in multiple tumor specimens from individual patients with breast cancer

Receptor conversion in metastatic breast cancer: analysis of 390 cases from a single institution

Estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 (HER2) status provide clinical utility in guiding therapeutic decision-making in metastatic breast cancer (BC). Increasing data have shown substantial differences between the receptor profiles of primary BCs and their paired metastases. In this study, we provide a large single center cohort to assess the frequency of receptor conversion in metastatic BC. The overall discordant rates were 18.3%, 40.3%, and 13.7% for ER, PR, and HER2, respectively. The discordance was significantly higher for PR when compared with ER and HER2. The conversion occurred significantly as a switch from positive to negative receptor status when compared with that from negative to positive for all three receptors. Semiquantitative analyses revealed a significantly decreased expression of both ER (25%) and PR (57%) in the metastases. There was a higher rate of PR discordance in bone metastases when comparing to other common organs of relapse. Furthermore, in the subset of patients with a single primary and multiple distant metastases, the discordant rates among the distant sites were 27.5%, 39.4%, and 14.3% for ER, PR, and HER2, respectively. A positive ER status, be it in primary or metastatic BC, was associated with a prolonged metastasis-free survival when compared with ER-negative primary tumors without conversion. Furthermore, a positive ER status in metastatic BC regardless of primary was associated with a superior overall survival when compared with an ER-negative tumor without conversion. Thus, receptor conversion is a frequent event in the course of BC progression, and can also be seen between different metastatic sites. Moreover, some conversions are of prognostic significance. The findings may reflect tumor heterogeneity, sampling or treatment effect, but may also indicate alteration in tumor biology. Repeat biomarker testing is warranted in making appropriate treatment plans in the pursuit of precision medicine.

Distribution of Estrogen and Progesterone Receptors in Primary Tumor and Lymph Nodes in Individual Patients with Breast Cancer

Primary breast cancer tissue and lymph nodes were obtained from 48 patients. Estrogen receptors (ER) and progesterone receptors (PgR) were determined by a dextran-coated charcoal assay. ER were present in 72.9 % of the primary tumors and in 62.4 % of the malignant lymph nodes, whereas PgR were present in 73.0 % and 50.0 % of the cases, respectively. The primary tumor and the corresponding malignant lymph nodes showed an identical ER and PgR status, i.e., both tumor sites were receptor positive or both receptor negative in 89.6 % and 77.1 %, respectively. However, 10.4 % of the patients had ER-positive tumors but ER-negative lymph nodes and 22.9 % had PgR-positive primaries with PgR-negative lymph nodes. No receptor-positive lymph nodes showed a combination with receptor-negative primary tumor. This preliminary data shows that receptor-positive malignant lymph nodes mostly display the same receptor status as the corresponding primary tumor, whereas receptor-negative lymph nodes may have a receptor-positive primary tumor.

Variability in hormone and growth factor receptor expression in primary versus recurrent, metastatic, and post-neoadjuvant breast carcinoma

The introduction of selective molecular targeted therapy, specifically tamoxifen and trastuzumab, has significantly altered the clinical behavior of breast carcinoma. Several questions remain, however, regarding potential phenotypic drifts in estrogen receptor (ER), progesterone receptor (PR), and epidermal growth factor receptor (Her-2/neu) expression between the primary and metastatic site. Whether patients should be tested for ER, PR, and Her-2/neu expression in the nodal or distant metastatic site, local recurrence and following neoadjuvant therapy, and whether this has an effect on prognosis remains elusive. A review of 45 studies addressing ER, PR, and Her-2/neu expression in lymph node metastasis, distant metastasis, local recurrence, and post-neoadjuvant therapy revealed the following average phenotypic drift in ER, PR, and Her-2/neu expression, respectively: 13.1 % (median = 10.0 %), 13.8 % (median = 16.0 %), and 7.7 % (median = 5.0 %) for lymph node metastasis; 21.8 % (median = 19.5 %), 30.8 % (median = 33.5 %), and 7.6 % (median = 6.1 %) for distant metastasis; 19.8 % (median = 13.4 %), 27.1 % (median = 28.6 %), and 6.6 % (median = 1.6 %) for local recurrence; and 12.9 % (median = 8.0 %), 32.0 % (median = 20.0 %), and 8.9 % (median = 0 %) post-neoadjuvant therapy. The above findings support the notion of re-evaluating ER, PR, and Her-2/neu expression in distant metastasis, lymph node metastasis and to a lesser extent local recurrence. The effects of neoadjuvant therapy on receptor expression are more pronounced for PR, which may have a prognostic role in therapy efficacy.

[Hormone receptors and HER-2 changes during breast cancer progression: clinical implications]

Breast cancer remains a major public health problem. Even if there is an increase in this cancer curability, metastatic breast cancer remains a lethal disease in the vast majority of cases. Therapeutic advances in the chemotherapeutic and targeted therapies fields induced an increase in survival, however the proportion of long survivors remains low. Phenotypic instability, an early process initiated during tumour progression, and continued on the metastatic stage of the disease, can be one of the putative hypotheses explaining these results. An increasing amount of scientific data are pledging for a reanalysis of the phenotypic profile regarding hormone receptors and HER-2 status of metastatic lesions in order to identify drugable targets and allow individualisation of the treatment of these metastatic breast cancer patients. Phenotypic changes between the primary tumour and the paired metastatic lymph nodes are a challenging pitfall, raising the question of which site has to be assessed in the adjuvant treatment decision process. This article presents a comprehensive analysis of the frequency of theses phenotypic changes altogether with new modalities to evaluate this phenotypic status.

Hormone receptor and c-ERBB2 status in distant metastatic and locally recurrent breast cancer. Pathologic correlations and clinical significance

Estrogen receptor (ER), progesterone receptor (PR), and c-ERBB2 (HER2/neu) are therapeutically and prognostically important markers in the management of breast carcinoma. They are not always analyzed in distant metastatic and locally recurrent breast cancers. We compared immunohistochemical expression in a series of primary breast carcinomas with their distant metastases (n = 72) and local recurrences (n = 45) and analyzed the impact of any changes on survival. Discordance rates between primary and metastatic and between primary and locally recurrent lesions, respectively, were 18% (13/72) and 13% (6/45) for ER, 42% (30/72) and 33% (15/45) for PR, and 7% (5/72) and 2% (1/45) for c-ERBB2. There was statistically significant discordance between primary and metastatic PR status (P = .017; kappa = 0.201). Among locally recurrent tumors, 15 (33%) of 45 revealed discordance for PR (P = .006; kappa = 0.366). We observed a trend for shorter survival among women with ER- metastatic and locally recurrent tumors regardless of the primary tumor ER status. Our findings suggest a benefit for routine evaluation of ER, PR, and c-ERBB2 status in distant metastatic and locally recurrent breast cancer for therapeutic and prognostic purposes.

EGFR, c-erbB2 and p53 protein in the primary lesions and paired metastatic regional lymph nodes in breast cancer

AIMS

Various biological parameters are now being evaluated as predictors for the response of chemohormonal therapy for breast cancer. Few studies compare these parameters between the primary lesions and metastatic regional lymph nodes of breast cancer.

METHODS

Immunohistochemical analyses for epidermal growth factor receptor (EGFR), c-erbB2 and p53 protein were performed on the primary lesions and matching metastatic regional lymph nodes of 107 breast cancers. The intensity of the immunoreactivity was graded for heterogeneous or 10-50% staining, and diffuse or >50% staining.

RESULTS

EGFR, c-erbB2 and p53 protein showed a concordance between the primary lesions and matching regional lymph nodes in terms of a negative or positive finding (+ and ++) in 98 (92%) of 106 cases, 76 (100%) of 76 cases and 79 (93%) of 85 cases respectively, while EGFR, c-erbB2 and p53 protein also showed a concordance in the intensity of the immunoreactivity in 24 (89%) of 27 cases 14 (74%) of 19 cases and 30 (94%) of 32 cases respectively. In 21 of 24 cases which showed a disconcordance in the positivity or the intensity of the positivity of EGFR, c-erbB2 and p53 protein, one of the primary lesions and matching regional lymph nodes showed heterogeneous or 10-50% immunostaining.

CONCLUSIONS

The immunoreactivity of EGFR, c-erbB2 and p53 protein shows a concordance between the primary lesions and matching metastatic regional lymph nodes in a majority of breast cancers.

Validation of tissue microarray technology in breast carcinoma

The recent development of tissue microarray technology has potentiated large-scale retrospective cohort studies using archival formalin-fixed, paraffin-embedded tissues. A major obstacle to broad acceptance of microarrays is that they reduce the amount of tissue analyzed from a whole tissue section to a disk, 0.6 mm in diameter, that may not be representative of the protein expression patterns of the entire tumor. In this study, we examine the number to disks required to adequately represent the expression of three common antigens in invasive breast carcinoma--estrogen receptor, progesterone receptor, and the Her2/neu oncogene--in 38 cases of invasive breast carcinoma. We compared the staining of 2 to 10 microarray disks and the whole tissue sections from which they were derived and determined that analysis of two disks is comparable to analysis of a whole tissue section in more than 95% of cases. To evaluate the potential for using archival tissue in such arrays, we created a breast cancer microarray of 8 to 11 cases from each decade beginning in 1932 to the present day and evaluated the antigenicity of these markers and others. This array demonstrates that many proteins retain their antigenicity for more than 60 years, thus validating their study on archival tissues. We conclude that the tissue microarray technique, with 2-fold redundancy, is a valuable and accurate method for analysis of protein expression in large archival cohorts.

Sequential estrogen receptor determinations from primary breast cancer and at relapse: prognostic and therapeutic relevance. The International Breast Cancer Study Group (formerly Ludwig Group)

We retrospectively evaluated 401 selected patients who had estrogen receptor (ER) assays both at primary surgery and at relapse in an accessible site to determine the clinical relevance of the subsequent ER determination. The median time between ER assessments was 27 months (range: 2-122 months). The median follow-up time from diagnosis was 6 years (range: 2-12 years). For patients with ER+ tumors at primary diagnosis, 29% (76/261) had ER- tumors at relapse, while for ER- primaries, the conversion rate was 33% (46/140). Conversions from ER+ to ER- occurred more often when the time interval between assays was less than one year (p = 0.004), while conversions from ER- to ER+ tended to occur late (beyond three years; p = 0.0003). Treatments received between assays (usually adjuvant therapy) had only a slight influence on ER status conversion. Post-relapse survival was poor for patients who had the biopsy accessible recurrence within one year; an expression of the aggressive nature of the disease. Among patients whose accessible relapse was beyond one year, those with ER- primaries who converted to ER+ had a longer survival than those whose recurrence was classified again as ER- (p = 0.006). This group of patients with ER- primaries who recurred beyond one year with an ER+ tumor in an accessible site represented 29% (40/140) of all patients with ER- primaries and had an estimated overall survival rate of more than 60% at 6 years from the accessible relapse. ER determination upon relapse within one year has very little clinical relevance.(ABSTRACT TRUNCATED AT 250 WORDS)

Determination of estrogen receptors in paraffin-embedded tissue. Techniques and the value in breast cancer treatment

Estrogen receptor (ER) analysis in breast cancer has been used in three clinical situations: to select patients with advanced breast cancer for hormonal therapy, as a prognostic parameter, and for selection of women with early breast cancer to adjuvant hormonal treatment. ER has traditionally been measured using labelled hormone in binding assays--often in dextran-coated charcoal assays (DCC). Monoclonal antibodies to ER has permitted development of a solid phase enzyme immunoassay (ER-EIA) used for quantitative determination of ER in tissue homogenates, and have also been used for determination of ER using an immunohistochemical assay in frozen sections (ER-ICA) or in formalin-fixed, paraffin-embedded tissue (ER-PAR). A large number of studies has compared ER-EIA with ER-DCC assays. There is a good linear correlation between the two types of assay but ER-EIA measure more ER and classify a larger fraction of tumors ER-positive than conventional ER assays. Lack of clinical data makes the significance of this uncertain. Numerous studies have reported on the correlation between ER-ICA and ER-DCC or ER-EIA. There is a good correlation among the assays on classification of ER status with a median 86% concordance, but a somewhat poorer correlation between semiquantified ER of immunohistochemical assays and ER determined by the quantitative methods (median coefficient of correlation 0.67). There is a large variation in the cut-off level for definition of ER-positive in immunohistochemical assays emphasizing the need for quality control studies. The major problem involved in ER analysis in paraffin-embedded tissue is a considerable loss of immunoreactivity compared to sections from frozen tissue. This can partly be overcome by modifications of the immunohistochemical technique using enzyme pretreatment and other amplification systems, but the sensitivity of ER-PAR remains lower than ER-ICA despite these modifications, and the ER status is less reliably determined in tumors with low ER contents (< 100 fmol). The prognostic value of ER-PAR was evaluated with a multivariate analysis. The endpoint was disease-free interval in systemically untreated patients with early breast cancer, and the variables used were: ER-DCC, ER-PAR, age, tumor size, tumor grade, and nodal status. A total of 133 patients from the Danish Breast Cancer Cooperative Group's (DBCG) 77c protocols had a complete set of variables. The analysis showed that only nodal status, ER-DCC, and tumor grade were significant and independent prognostic variables. An overview of larger multivariate studies on mainly node-negative patients failed to show independent prognostic significance of ER-DCC.(ABSTRACT TRUNCATED AT 400 WORDS)

Oestrogen and progesterone receptor status in bone biopsy specimens from patients with breast cancer

Of 16 breast cancer patients with histologically proven, tumour-infiltrating biopsy specimens most had low ER and PR values; the ER and PR contents varied between 0 and 135 and 0 and 44 fmol/mg protein, respectively. With the conventional clinical threshold of 10 fmol/mg protein, 8 specimens (50%) were ER-PR-, 4 (25%) ER-PR+, 3 (19%) ER+PR+ and 1 (6%) ER+PR-. ER levels were significantly lower in the tumoral bone lesion compared with the primary tumour. For 15 patients with negative biopsies and without endocrine treatment, ER and PR concentrations were quantifiable (2 fmol/mg protein or more) in 9 (60%) and 11 cases (73%), respectively. 8 of 9 patients over 55 (89%) were ER+ (2 fmol/mg protein or more). Conversely, for patients under 55, 1 of 6 (17%) was ER+ (P less than 0.001). Results for PR were similar. These data strongly suggest that steroid receptors are present in healthy bone tissue.

Response to second-line hormone treatment for advanced breast cancer. Predictive value of ploidy determination

Twenty-two patients who previously responded to first-line hormonal therapy were evaluated for factors which would predict for response to second hormonal manipulation. Investigations performed at progression after initial hormone response included immunocytochemical estimation of estrogen and progesterone receptors as well as flow cytometric analysis of tumor ploidy. Approximately 50% of patients were found still to be estrogen receptor positive at relapse from first-line hormone treatment. Progesterone receptor had, however, usually become negative. Nine of the 22 patients responded to second-line hormonal therapy. Second hormone responses occurred with equal frequency among hormone receptor-positive and hormone receptor-negative patients. Tumor ploidy, as determined by flow cytometric study did, however, predict for response. Eight of 12 patients with diploid tumors responded to second-line hormone therapy whereas only one of ten with aneuploid tumors responded. Flow cytometric analysis appears to be a promising technique for prediction of second hormone response after relapse from first-line hormone manipulation.

Immunohistochemical detection of estrogen receptors in paraffin sections from primary and metastatic breast cancer

With the availability of monoclonal antibodies against the estrogen receptor (ER) it is possible to demonstrate the presence of ER immunohistochemically. Some of the antibodies are claimed to be reactive in formalin fixed, paraffin embedded tissue. We have evaluated the reactivity of one of these antibodies, D75 and found an acceptable reaction in routinely formalin fixed, paraffin embedded tissue. The antibody was applied to both primary and secondary tumors from a group of patients with recurrent breast cancer. The metastatic lesions consisted of lymph node metastases, bone marrow metastases, and liver metastases. While 41% of the primary tumors were ER-positive, this was only the case with 35%, 20%, and 17% of the lymph node, bone marrow, and liver metastases, respectively. The discordance between the ER-status of the primary tumor and the distant metastasis was 41% in cases of bone marrow metastases, and 44% in liver metastases. In most cases the shift was from an ER-positive primary tumor to an ER-negative metastasis. The results support the hypothesis that ER-negative tumor cells are probably more aggressive with a larger metastatic potential than the higher differentiated, ER-positive tumor cells.

Measurement of oestrogen receptor mRNA levels in human breast tumours

A sensitive single-stranded hybridisation probe for the oestrogen receptor mRNA was synthesised using T3 polymerase from oestrogen receptor cDNA cloned in the Bluescript vector. This probe was used to measure oestrogen receptor mRNA in total RNA extracted from breast tumours. Oestrogen receptor mRNA was detected in 41 of 47 (87%) tumours whereas cytosolic oestrogen receptor protein was detected in only 18 out of 39 (46%). There was a significant correlation between the levels of the oestrogen receptor, as measured by 3H-oestradiol binding, and the oestrogen receptor mRNA. Oestrogen receptor mRNA was detected in 15 of the 21 tumours that did not contain detectable oestrogen receptor protein. This suggests that detection of the mRNA is a more sensitive means for establishing oestrogen receptor status than the radioligand oestrogen receptor assay. Oestrogen receptor mRNA was found in all histological tumour types examined. Its level was related to tumour differentiation. All the tumours that did not contain oestrogen receptor mRNA and most of the tumours that contained only low levels of oestrogen receptor mRNA were classified as grade III according to Bloom and Richardson: the median of the oestrogen receptor mRNA levels was significantly lower in this group.

Hormone receptor assays: clinical usefulness in the management of carcinoma of the breast

The revision of the subcellular model of hormone action is described, with an incorporation of potential autocrine mechanisms. A general overview of available assay methodologies considers the major disadvantages of earlier methods and describes in detail the current methodologies (sucrose gradient analysis, dextran-coated charcoal assays, ER-EIA, ERICA). A major concern with clinical correlations of response to hormone receptor levels is the quality assurance of the multicentric programs. Results from national and international programs are considered. The clinical correlations are divided into four major categories: (1) the response to hormone deprivation (oophorectomy or adrenalectomy), (2) the development of specific agents which exploit receptor mechanisms (antiestrogens) or inhibit steroid biosynthesis (aminoglutehimide), (3) the rates of recurrence of tumors following mastectomy, and (4) the correlation of hormone receptors with current adjuvant therapies.

Relationship between estrogen receptor status in the primary tumor and its regional and distant metastases. An immunohistochemical study in human breast cancer

Treatment of metastatic breast cancer based on the estrogen receptor content (ER) of the primary tumor builds on the assumption that the ER status of the primary tumor and the metastases are largely equal. Studies addressing this question have used ligand-binding assays for ER determination and have consequently been subject to the limitations of this technique. Reported disparity rates have been 20%. In order to avoid some of these limitations, we used an immunohistochemical assay in paraffin-embedded tissue. Among a total of 92 examined regional lymph node metastases, ER status was equal with that of their 37 primaries in 84 cases (91%). Semiquantified ER content was significantly correlated in primary tumor and the metastases (r = 0.67, p less than 0.001). Among a total of 51 distant metastases, equal ER status was found in 44 (86%) cases and a quantitative relationship could not be established. Disparities can be due to methodological errors in the histochemical assay or tumor heterogeneity.

Stability of oestrogen receptor status in sequential biopsies from patients with breast cancer

Sequential biopsies of breast cancer tissue were obtained from a total of 210 women in order to assess any change in oestrogen receptor (ER) status arising spontaneously or as a result of intervening therapy. A combined assay measuring both cytosol and nuclear oestrogen receptors was used for all samples. One hundred and fifty-five patients had biopsies of their primary tumour and of a later loco-regional recurrence; 26 had biopsies of their primary tumour and a recurrence or new primary in the opposite breast; and 29 had sequential biopsies of recurrent disease only. Overall only 61.2% of the primary tumours retained their original status with respect to both cytosol and nuclear oestrogen receptors on recurrence. These results were influenced by intervening therapy, however, and if only untreated patients are considered, over 70% of their recurrences contain the same combination of cytosol and nuclear receptors as found in the primary tumours. For tumours 'recurring' in the opposite breast, the pattern was similar with 69.2% retaining the same status as the first primary. The agent found most likely to alter I:R status was tamoxifen and in the samples taken from patients undergoing treatment with this drug, no tumour was found to contain measurable receptor.

Androgen receptors in biopsy specimens of prostate adenocarcinoma. Heterogeneity of distribution and relation to prognostic significance of receptor measurements for survival of advanced cancer patients

Needle biopsy specimens of primary adenocarcinoma and surgical specimens of carcinomatous nodal tissue were obtained from previously untreated clinical D stage prostatic adenocarcinoma patients. Assessment of the relation between specimen androgen receptor site content and survival using either scatterplots or Kaplan-Meier analyses showed specimen receptor content was a poor prognostic P greater than 0.1, of survival subsequent to orchiectomy or diethylstilbestrol (DES) therapy. The possibility that heterogeneity of specimen androgen receptor site content contributed to this finding was evaluated by comparing receptor content of multiple small or large tissue specimens from the same prostate gland of patients with benign prostatic hyperplasia or nonmetastatic prostatic cancer. This evaluation showed significant microheterogeneity of human prostate androgen receptor site content which was substantially masked in large tissue specimens. We conclude that microheterogeneity of human prostate androgen receptor site content compromises the use of biopsy specimen androgen receptor measurements as a prognostic of patient survival subsequent to initiation of hormonal therapy.

Infiltrating lobular carcinoma of the breast: response to endocrine therapy and survival

The records of 480 patients who received systemic therapy for advanced breast cancer in the University Hospital of South Manchester from 1975 to 1983 were examined. There were 264 with infiltrating duct carcinomas (IDC) and 33 with infiltrating lobular carcinomas (ILC) for whom the response to endocrine therapy was known. There were 92 responses (35%) among the IDC patients and 9 (27%) among the ILC patients. Sixty-seven per cent of IDC patients tested had steroid hormone receptor positive tumours compared to 90% for ILC (P less than 0.001). Comparison of survival from diagnosis, disease free interval and survival from relapse showed no significant differences between the two groups. Thus despite almost all ILC patients having hormone receptor positive tumours their survival was similar to that of IDC patients. This appears to be due to a lower than expected response rate to endocrine therapy. This is a further indication of the different biological characteristics of these two histological sub-types of breast carcinoma.

Short-term chemotherapy of poor-prognosis metastatic breast cancer with three non-cross resistant chemotherapy regimens. A Southwest Oncology Group Study

A Southwest Oncology Group pilot study was designed to evaluate a brief, 4.5-month induction course of chemotherapy with three presumably non-cross resistant regimens in poor-prognosis metastatic breast cancer. Sixty-three patients were treated with doxorubicin, cyclophosphamide, plus vincristine on day 1, methotrexate followed 30 minutes later by 5-fluorouracil (5-FU) on day 22, and mitomycin C plus 3 days of vinblastine on day 43. All three sequential regimens were repeated once and therapy was then discontinued in responding patients. The same chemotherapy was reinstituted at the time of relapse. The overall response rate to the induction chemotherapy was 35% and included only one complete response (2%). Median response duration was 9 months. Respondents were off all therapy for a median of 5 months (range, 1-12+ months) and were followed without evidence of progressive disease. Response to retreatment was 30% with no complete responses seen. Overall median survival from the data of diagnosis of metastatic disease was 24 months, with a median survival of 14 months from the date of initiation of therapy. Toxicity for this induction regimen was moderate with two treatment-related deaths secondary to myelosuppression. While the results of this pilot study fail to support the use of non-cross resistant regimens in breast cancer, short-term therapy appears to have no adverse effect on survival and resulted in significant periods during which no therapy was given, resulting in a reduction in overall toxicity.

Metastatic pattern and response to endocrine therapy in human breast cancer

The effect of endocrine therapy in 465 postmenopausal patients with advanced breast cancer who entered four consecutive, randomized trials has been related to the site of the metastases. Patients received either tamoxifen (T) alone or T in combination with medroxyprogesterone acetate, diethylstilbestrol, halotestin, or aminoglutethimide. The overall response rate was 40%. Responses were most frequently seen in patients with metastases in soft tissue, and the duration of response to endocrine therapy in these patients was longer than for those with metastases in bone or viscera (p less than 0.00001). In addition, the response rate was inversely correlated with the number of main metastatic sites in patients with soft tissue metastases, whereas the response rate was not associated with the number of metastatic sites in patients with metastases in bone and viscera. Survival after first recurrence was significantly longer in responding patients with soft tissue lesions compared to those with recurrence in bone or viscera. In contrast, survival after first recurrence was identical in patients with nonresponding disease, irrespective of dominant site of metastases. The outcome of endocrine therapy depends partially upon the dominant site of metastases. This may reflect a difference in biological characteristics of human breast cancer tumor cells that metastasize to different sites.

The predictive value of estrogen and progesterone receptors' concentrations on the clinical behavior of breast cancer in women. Clinical correlation on 547 patients

The aims of this study were as follows: to confirm that the presence of estrogen (ER) and progesterone (PgR) receptors is an indicator of clinical behavior of human breast cancer independent of other known prognostic factors; to seek clinical correlates of those receptor values that best predict the overall disease evolution; and to determine the relative prognostic importance of PgR versus ER. The clinical records of 547 patients, the follow-up of some extending to 6 years, were analyzed in retrospect. Patients were placed into one of four disease stages and also in three groups according to the degree of axillary node involvement. In each group the prognostic value of receptors for patient survival, disease-free interval and, in case of metastasis or local recurrence, the response to endocrine treatment or chemotherapy were studied. The break point in the spectrum of receptor concentrations with regard to survival, disease-free interval, and response to treatment was greater than or equal to 20 for ER+, greater than or equal to 15 for PgR+, and less than 5 for both ER- and PgR- reported in fmol/mg protein. Survival and disease-free interval showed positive correlations with ER and PgR (P less than 0.001-less than 0.0003). When disease stage or node involvement were considered, these correlations were found essentially in Stage II and node involvement in more than three nodes, where patients had longer survival and disease-free interval if ER and PgR were positive (P less than 0.05-less than 0.0003). Estrogen receptor was a more sensitive prognostic indicator than PgR, and the combination ER+/PgR+ showed a correlation equivalent to ER+/PgR-. The correct prediction percentages of the response of patients to endocrine treatment were 77% if ER+, 69% if PgR+, and 79% if both ER+ and PgR+. However, the correct prediction percentage of the response to chemotherapy was of 50%. These results show that ER and PgR are prognostic factors for survival and disease-free interval mainly on patients at Stage II and node involvement of greater than three, with ER demonstrating a better predictive value than PgR. The measurement of these receptors provides a prognostic index for response to endocrine therapy but is without value in predicting the response to chemotherapy.

The effects of therapy on estrogen receptors in breast cancer

The importance of estrogen receptors (ER) in predicting the results of therapy in advanced-stage breast carcinoma is now generally accepted. It is, therefore, important to know whether therapy itself, besides other factors, could affect ER status. The aim of the authors was to investigate this problem by reviewing the data from the literature. They have taken into account the effects of hormonal and/or chemotherapy and of radiotherapy, moreover, they have considered the importance of the time elapsed since the suspension of treatment. Hormonal therapy appears to be the kind of treatment more clearly correlated with a loss of ER: the authors have reported some hypotheses about the possible mechanisms of this action. The effect of chemotherapy is much less clear; the data about radiotherapy are few, unhomogeneous and, often, insufficient. Instead, it appears quite clear that ER tend to regain their original status after the suspension of therapy. More studies, are needed before any definitive conclusion can be drawn; it will be necessary to take into account also the possible effect of the different criteria for the preselection of patients. The actual data appear, anyway, to confirm the importance of routine receptor assay on breast tumors, especially after systemic treatment and independently of the kind of therapy itself.

The relationship between estrogen receptors in primary and secondary breast carcinomas and in sequential primary breast carcinomas

A review of over 2000 patients who had estrogen receptors (ER) assayed in the primary breast carcinoma identified 48 cases in whom a subsequent second primary breast carcinoma or concurrent or recurrent secondary tumour had been tested for ER status. The relationship between the ER in the two specimens was as follows: Of 14 concurrent primary and secondary breast carcinomas the ER concentration was the same in 11 cases; in 1 case it was significantly higher in the primary tumour, in 2 others the reverse was observed. There was no major discordance in ER status. In 14 sequential carcinomas (after an average disease free time of 21 months), 12 pairs had identical ER status. There was major discordance of ER status in 2 cases where the secondary tumours contained ER while the primary carcinoma did not. The ER concentrations in the primary and the secondary carcinomas were comparable in 8 cases, while 3 and 5 cases had significantly higher or lower concentrations respectively in the sequential secondary tumour. In 20 cases where breast cancer developed in the contralateral breast (after an average disease-free interval of 27.7 months), essential concordance of ER status was observed in 15 of 20 sequential carcinomas. In 5 patients the first carcinoma was ER- and the second ER+; in one additional patient the first carcinoma was ER +/- and the second ER-. The ER concentrations differed significantly in 14 of the 20 bilateral carcinomas. The literature on estrogen receptor variation in breast carcinoma was reviewed.

Simultaneous and sequential determinations of steroid hormone receptors in human breast cancer. Influence of intervening therapy

Estrogen (ER), progesterone (PgR), and androgen (AR) receptors were measured in two simultaneous or subsequent specimens taken each from 259 patients with breast cancer. We studied in 182 patients results from receptor assays, either from one tumor or from the primary tumor, and a lymph node metastasis, and in 77 sequential biopsies with or without intervening therapy. All assays were performed in a single laboratory, considering 10 fmol/mg cytosol protein bound ligand as receptor positive. The concordance rate in simultaneous ER assays was 85%; however, we found a considerable high discordance rate for PgR in primary tumor and lymph node metastasis (25%). The overall discordance rate in sequential biopsies for ER was 38% and for PgR 25%. This discordance rate was primarily dependent on the receptor quality of the first assay (ER+: 50%, ER-: 24%, PgR+: 68%, PgR-: 9%). Considering only the ER+ and PgR+ cases, we found the greatest discordance rate in the patients having endocrine treatment following the first biopsy (55% and 84%, respectively). We conclude that the receptor status of one tumor biopsy is highly representative for other tumor or lymph node biopsies. Because of the high discordance rate of primarily receptor + cases in subsequent recurrences, the receptor quality of these lesions should be analyzed whenever possible.

Changes of steroid hormone receptor content by chemotherapy and/or endocrine therapy in advanced breast cancer

In several sequences during the progression of cancer, the authors assayed estrogen receptors(ER) in 940 breast cancers and progesterone receptors(PgR) in 773 cancers. The percentages of ER+ and PgR+ cancers diminished according to the progression of malignancy. Sequential assays of ER and PgR were carried out in primary tumors and in the metastatic tumors at the first recurrence in 42 patients. During the disease-free interval, 10 (37%) of 27 ER+ tumors changed to ER- and all 15 ER- tumors remained negative. The hormone receptors were assayed before the treatments and after the tumor relapsed following regression or after the progression of cancer. The change of ER and PgR in 99 patients with advanced breast cancer were studied according to the type of systemic treatments. Through endocrine therapy, marked changes from ER+ to ER-, were noted (by antiestrogens, 47% [7/15]; by adreno-oophorectomy, 61% [11/18]). Almost no breast cancers changed from ER- to Er+ during the endocrine therapy (by antiestrogen, 1/6; by adreno-oophorectomy, 0/10). All of six PgR+ tumors changed to PgR- after therapy. By chemotherapy treatment, 44% (4/9) ER+ cancers became ER-, while 19% (3/16) ER- tumors changed to ER+. After the simultaneous combination of chemotherapy and endocrine therapy, 67% (10/15) of ER+ cancers changed to ER-, and 20% (2/10) of ER- tumors changed to ER+. Through the intervention of more than two kinds of chemotherapy and/or endocrine therapy between the first treatment and the last therapy, 79% (19/24) ER+ breast cancers changed to ER-. Thus, ER and PgR contents of breast cancer gradually became negative as the malignancy progressed, and with some kinds of treatments particularly including endocrine therapy. The significance of changes in hormone receptors after therapy was discussed.

Concordance and discordance of estrogen and progesterone receptor content in sequential biopsies of patients with advanced breast cancer: relation to survival

In 75 patients with advanced breast cancer, sequential biopsies were analyzed for estrogen receptor (ER). In 50 of these patients progesterone receptor (PgR) was also measured. All pairs of biopsies met the following criteria: (i) interval between the two biopsies: at least 6 weeks; (ii) biopsies performed at least 6 weeks after stopping endocrine therapy; and (iii) concordant histology. Discordance in ER was found in 14 of 75 patients (18.7%); PgR was discordant in 14 of 50 patients (28.0%). No significant differences were found between concordant and discordant groups of patients in age at first diagnosis, menopausal state, diameter of the primary tumor, time interval between the two biopsies and intervening therapy. The initial ER level in patients whose ER changed from positive to negative was significantly lower than in patients whose ER remained positive. PgR levels exhibited a rise only when ER rose at the same time. Sequential assays have increased the prognostic significance of ER and as a consequence the estimated survival time for patients whose tumors were ER-negative in both biopsies was significantly shorter than for patients whose tumors were ER-negative in only one of the two biopsies. We found no prognostic significance for PgR in either single measurements or repeated biopsies.

Breast cancers: estrogen and progesterone receptor status as a predictor of in vitro chemotherapeutic response

Although clinical observations have shown that estrogen receptor-positive (ER+) breast tumors are more responsive to hormonal therapy than ER-negative (ER-) tumors, it remains controversial whether ER status can predict chemotherapeutic response. To determine if there was any correlation between estrogen and progesterone values and in vitro chemosensitivity to various anticancer drugs, clonogenic (CA), estrogen (ERA), and progesterone (PRA) assays on breast cancers were performed on 100 patients. Clonogenic assays were performed using the double-layer soft agar technique with continuous drug exposures. ERAs and PRAs were performed using the charcoal-coated dextran method. Chemosensitivity was defined as 50% inhibition of colony formation. ERA was considered positive if greater than or equal to 5 fmole/mg cytosol and PRA positive if greater than or equal to 10 fmole/mg cytosol. Significant tumor growth (greater than 30 colonies/plate) was achieved in 81/100 assays. ERA and PRA values were not predictive of colony formation in vitro. Of all agents or combinations of agents tested (L-PAM, 5-FU, MTX, adriamycin, vinblastine, cis-plat, FAC, CMF), only the response to 5-FU correlated significantly with ERA. Eight of 11 (73%) of the ER- tumors were sensitive to 5-FU, whereas only 6/20 (30%) of ER+ tumors were sensitive (P less than 0.05). ER- tumors were also more likely to be sensitive to CMF (P = 0.09) and adriamycin (P = 0.07) than ER+ tumors. PRA values were not predictive of chemosensitivity, nor did combining PRA and ERA enhance the predictive value of ERA alone.

Receptor heterogeneity of human breast cancer as measured by multiple intratumoral assays of estrogen and progesterone receptor

Multiple intratumoral tissue samples from the primary mass of 30 consecutive invasive breast cancer patients were assayed for estrogen receptor (ER) and progesterone receptor (PR) by the dextran-coated charcoal method following frozen section histopathological examination. Steroid receptor status of each sample was classified as positive (R+) or negative (R-), based only upon quantitative guide lines from the ER/PR results. Four out of 32 (12.5%) of the invasive cancers had an intratumoral sample classified as R+ and one sample as R-. R+ invasive ductal carcinomas has a highly significant degree of tubule formation (P = 0.005) when compared with R- invasive ductal cancers. While the quantitative ER content (r = 0.18) and the degree of quantitative variation in ER content (P = 0.04) did not correlate with the tumor cellularity of the individual samples, tumor cellularity (P = 0.005) and ER content (P = 0.005) were lower in the samples from the tumor border than from the central tumor samples. Variations in ER and PR content may be found on a regional basis within a breast tumor mass resulting from heterogeneity of tumor subpopulations and/or differences in tumor cellularity.

Variation in receptor status between primary and metastatic breast cancer

Steroid hormone receptors for oestradiol (ER) and progesterone (PR) have been measured sequentially in primary and metastatic breast cancer to determine whether receptor status remains concordant in individual patients. Serial receptor measurements from the same tumor site showed a change from receptor-positive to receptor-negative tissue with time in some patients. Receptors were measured in primary tumor and later metastatic disease or tumor of the contralateral breast in 28 patients. Concordant results were found in 46% of cases. Six of nine patients with ER-positive primary tumors developed ER-negative metastases and four of five PR-positive primary tumors were associated with PR-negative secondary deposits. Nine of 19 patients with ER-negative primary tumors later had ER-positive metastases, and three of 15 PR-negative primary tumors were associated with PR-positive secondary deposits. Possible false-negative ER measurements (ER-, PR+) in primary tumors, and interval treatment with chemotherapy or hormonal manipulation between biopsies may have contributed to these changes in receptor status. Six patients changing from receptor-negative primary tumors to receptor-positive metastases underwent hormonal therapy of metastatic disease, and four had objective responses to treatment. Care should be taken when using receptor measurements from primary breast tumors to help decide treatment for later metastatic disease.

The localization of 3H-estradiol in estrogen receptor-positive human mammary carcinoma as visualized by thaw-mount autoradiography

Biochemical assays of human mammary carcinomas for estrogen receptors (ER) are of proven clinical usefulness. The reliability of histochemical or immunocytochemical methods for ER localization are less well established, and less is known about the distribution of estrogen binding proteins in breast cancer. In this report we present results of a study of the uptake and retention of 3H-estradiol after in vitro incubation as visualized by thaw-mount autoradiography in five cases of biochemically estrogen receptor-positive breast cancer. These neoplasms appeared to be composed of a heterogeneous population of labeled and unlabeled tumor cells. The number of nuclear grains varied among putative target cells, and the relative percentage of labeled cells differed from area to area. Non-neoplastic mammary ductal epithelium on occasion revealed significant nuclear labeling, but stromal cells, inflammatory cells, and endothelial cells were generally negative. The possible significance of these findings is discussed.

Variation of receptor status in cancer of the breast

One hundred and nineteen patients with breast cancer had 2 or more lesions removed for oestrogen (REc) or progesterone receptor (RPc) assay, either synchronously (on 38 occasions) or after an interval (on 91 occasions). In all but 7 both receptors were assayed for each lesion. The assays did not agree on the presence or absence of REc alone, RPc alone or the combination of both receptors in 11, 13 and 16% respectively of the synchronous samples, compared with 23, 30 and 43% of the asynchronous samples. The differences between the synchronous and asynchronous samples were significant for the combined receptors (P = 0.007) but not for REc (P = 0.176) or RPc alone (P = 0.077). Variation between asynchronous biopsies was greater when the earlier lesion contained RPc (18/37 disagreed) than when it did not (8/50) disagreed, P = 0.0023). This was not true for oestrogen receptor. In those remaining receptor positive there was only a weak correlation between the first and second values (Spearman rank correlation coefficient, rho = 0.39 for REc, P less than 0.02, and 0.45 for RPc, 0.05 less than P less than 0.1). Receptor levels and receptor status may change with time. Biopsy is most appropriate at the time when systemic treatment is proposed.

Estrogen and progesterone receptors: correlation of response rates, site and timing of receptor analysis

156 patients with advanced breast cancer of known estrogen receptor (ER) and progesterone receptor (PgR) status treated by endocrine therapy were studied. Regarding values for ER and PgR greater than or equal to 5 fmole/mg cytosol protein as positive, patients were divided into 4 phenotypic subgroups: ER+PgR+ (43%), ER+PgR- (26%), ER-PgR+ (8%), and ER-PgR- (23%). In patients with tumor phenotype ER+PgR+, responses were seen in 20/30 (67%) assessable initial treatments when receptor assays were performed on tumor recurrence or on primary tumor immediately before endocrine therapy, and in only 11/32 (34%) assessable initial treatments when receptor analysis was performed on primary tumor and there was intervening local therapy before endocrine therapy was started for tumor recurrence (P less than 0.05). Responses to first endocrine therapy for each tumor phenotype were ER+PgR+ 50%, ER+PgR- 27%, ER-PgR+ 27%, and ER-PgR- 6%. Four of 16 (25%) patients with ER+PgR+ tumors responded to subsequent secondary endocrine therapy, but such responses were not observed in 20 patients with other tumor phenotypes. Duration of response was similar for each phenotype, but patients with ER-PgR- tumors had a significantly shorter survival from time of initial endocrine treatment than patients of any other phenotype. These results suggest that repeat steroid receptor assays on accessible tumor immediately before endocrine therapy may result in improved predictability.

Variability of steroid receptors in multiple biopsies of breast cancer: effect of systemic therapy

Estrogen receptor (ER) was measured on two or more specimens taken from each of 53 patients with carcinoma of the breast (18 also had progesterone receptor analyzed). Among the 35 patients who had no interval therapy, 27 patients had repeated tests within one month, and only two had reversal of ER results. Among the eight patients who had ER tests 9-36 months apart, four of five ER + lesions (7 + fmol/mg cytosol protein) had ER - metastasis. Among the 18 patients who received systemic therapy, three of ten ER + became ER -, while two of ten ER - became ER +. Our data and reports in the literature are summarized, showing that about 20% of receptor studies among multiple samples are different even when patients received no interval therapy. In asynchronous studies, it is more likely to have ER positive change to negative than vice versa (31% vs 12%). Interval chemotherapy or endocrine therapy tends to increase the occurrence of ER negative relapse among patients with ER positive tumors.

Multiple simultaneous and sequential estrogen receptor values in patients with breast cancer

Fifty-nine women had multiple estrogen receptor assays done, either simultaneously or sequentially. Eighty-six percent of the patients who had multiple synchronous estrogen receptor assays from various metastatic sites showed no significant discrepancy in estrogen receptor values. When estrogen receptor assays were done sequentially without intervening therapy, 83.5 percent of the patients maintained their initial positivity or negativity. However, when the second estrogen receptor determination was preceded by either chemotherapy or hormonal therapy, 33 percent of the patients had a significant discrepancy in estrogen receptor values. The most common discrepancy was estrogen receptor-positive tumors becoming estrogen receptor-negative, although a small number of patients were found whose receptor values became more positive after hormonal ablation.

Oestrogen receptor concentration in primary breast cancer and axillary node metastases

The primary tumour and 1-3 invaded, axillary nodes from each of 24 patients were examined both histologically for the proportion of the specimen constituted by malignant epithelial cells ('cellularity index') and biochemically for oestrogen receptor concentration. Both malignant epithelial cell content and oestrogen receptor concentration were significantly higher in the nodal metastases than in the primary tumours, malignant cells constituting approximately half of the former tissue and three quarters of the latter. On average, receptor concentrations were 1.6 x (protein basis) to 2.3 x (wet weight basis) higher in nodes than in the primary tumours, probably due at least in part to the difference in cellularity. When, to eliminate the effect of the latter, receptor concentration in each tumour deposit was 'corrected' using the appropriate 'cellularity index', the difference in receptor concentration between primary and node was significantly diminished, but not quite eliminated. In one patient, progestogen receptor concentrations were also studied and found to be higher in the nodes than in the primary tumour. If the actual quantity of receptor is to be used for predictive/prognostic purposes, then either a different 'cut-off point' should be used for invaded nodes from that used for assessment on the primary tumour, or receptor concentrations should be corrected for differences in cellularity.

Estrogen receptor protein in visceral metastases from breast carcinoma

Estrogen receptor protein assays were done on 1,243 tissue specimens, 34 of which represented metastases from primary breast carcinoma to parenchyma of liver, lung or brain. Eight of these specimens contained significant amounts of estrogen receptor protein. Most (4 of 5 evaluable cases) of the ERP-positive patients responded to endocrine ablation, as compared with 13 percent (2 of 16 evaluable cases) of the ERP-negative patients. We conclude that biopsy of liver and lung metastases may be useful in some circumstances and that endocrine manipulation frequently provides palliation when these metastases are ERP-positive.

Cholesterol content of serum lipoprotein fractions in children maintained on chronic hemodialysis

Breast cancer is the most common malignancy in women throughout the world. Metastatic dissemination to vital organs is the leading cause of breast cancer-related deaths. The treatment of metastases is mainly based on the primary tumor characteristics. However, breast cancer metastases exhibit high heterogeneity leading to different prognosis and therapeutic responses. Getting access to phenotype of metastases would allow better management of patients. The advent of theranostics in nuclear medicine has opened new opportunities for the diagnosis and treatment of cancer patients. The aim of this review is to provide an overview of current knowledge and future directions in nuclear medicine for therapeutic management of metastatic breast cancer patients.

Palliative therapy for metastatic breast cancer

Breast cancer may recur in the form of localized or generalized metastatic disease. Although localized metastasis is almost always evidence of more widespread occult disease, local therapy is often of prolonged palliative value. Generalized metastasis calls for systemic therapy, and hormone methods in many cases can provide long-term control before chemotherapy must be resorted to. The therapeutic approach depends on whether the patient is premenopausal or postmenopausal. Generally, ablative is more effective than additive hormone therapy. Whether a given patient will respond can be predicted to a degree by hormone receptor tests.