Preoperative assessment of prognostic factors in breast cancer

Accuracy of cytological grading in the carcinoma breast and its correlation with pathological prognostic parameters

BACKGROUND

Breast carcinoma is a significant contributor to cancer deaths worldwide. Tumor grade is an important parameter in planning out the treatment. Histology is the gold standard for grading the carcinoma breast. However, fine-needle aspiration cytology (FNAC) is still an important first-line diagnostic procedure in many parts of the world. Grading on cytology will help in pre-operative management. Although cytological grading of the carcinoma breast is a topic of research for many years, it is not yet included as a part of routine cytology reports.

MATERIALS AND METHODS

A prospective study was conducted over a period of 1 year at Kalinga Institute of Medical Sciences. A total of 42 cases of carcinoma breast, diagnosed on FNAC and subsequently confirmed on histology, were included. Cytological grading was performed using Robinson's grading system, and the results were compared with the histological grade. Also, the cytological grades were correlated with various pathological prognostic parameters such as tumor size, lymph node status, lympho-vascular invasion, estrogen and progesterone receptor status, Her-2-neu expression, and Ki-67 index. The kappa measure of agreement and Fisher's exact test were used for statistical analysis.

RESULTS

A moderate kappa measure of agreement (k = 0.415) was found between cytological and histological grades with an overall concordance rate of 66.67%. The accuracy of cytological grading was higher with increasing cytological grade. Except for estrogen receptor expression, none of the other prognostic parameters have a statistically significant correlation with cytological grade.

CONCLUSIONS

Tumor grading on cytology can be helpful in planning treatment, especially in resource-constrained settings. Subjective variation in assessing different parameters and non-inclusion of mitosis in this system might be the reasons behind wrong grading in some cases. Inclusion of mitosis in the scoring system can improve the accuracy of cytological grading and its importance in prognosis.

An Autophagy-Associated Prognostic Gene Signature for Breast Cancer

Autophagy is closely related to breast cancer and has the dual role of promoting and inhibiting the progression of breast cancer. In this study, we aimed to establish an autophagy-related gene signature for the prognosis of breast cancer. A gene signature composed of the eight most survival-relevant autophagy-associated genes was identified by least absolute shrinkage and selection operator (LASSO) regression analysis. A risk score was calculated based on the gene signature, which divided breast cancer patients into low- or high-risk groups and showed good and poor prognosis, respectively. The risk score displayed good prognostic performance in both the training cohort (TCGA, 1-10-year AUC > 0.63) and the validation cohort (GEO, 1-10-year AUC > 0.66). The multivariate Cox regression and stratified analysis revealed that the risk score was an independent prognostic factor for breast cancer patients. Moreover, the high-risk score was associated with higher infiltration of neutrophils and M2-polarized macrophages, and lower infiltration of resting memory CD4⁺ T cells, CD8⁺ T cells, and NK cells. Finally, the high-risk score was associated with myc target, glycolysis, and mTORC1 signaling. The risk score developed based on the autophagy-associated gene signature was an independent prognostic biomarker for breast cancer.

Comparison of clinical and magnetic resonance imaging findings of triple-negative breast cancer with non-triple-negative tumours

Purpose

Triple-negative breast cancer (TNBC) has some distinctive features. The aim of the study was to compare clinical and breast magnetic resonance imaging (MRI) findings of TNBC with non-triple-negative breast cancer (nTNBC) in molecular subtypes such as ADC (apparent diffusion coefficient) values, T2-weighted (T2W) image intensity, shape, margin, lymph node involvement, grade, multifocality, multicentricity, bilaterality, and enhancement pattern differences between tumour subtypes.

Material and methods

A total of 141 patients who underwent breast biopsy at our institution between January 2010 and June 2018 were included in this study. Patients were divided into molecular subtypes according to hormone receptor status, and Ki-67 index. Tumour grade, enhancement patterns, age, lymph node involvement, ADC values, breast imaging reporting and data system (BI-RADS) category, bilaterality, multifocality, multicentricity, margin, shape, and T2W image intensity were evaluated for these subtypes.

Results

ADC values were higher in triple-negative tumours than in luminal A and luminal B tumours (p = 0.010 and p = 0.002, respectively). Circumscribed margin, type 2 enhancement curve, and rim enhancement were significantly higher in triple-negative tumours (p < 0.001). No significant difference was found between the groups in terms of other MRI findings including bilaterality, multifocality, multicentricity, shape, and T2W image intensity (p > 0.05).

Conclusions

ADC values, circumscribed margin, and rim enhancement can provide important information about the tumour's biological behaviour and the course of the disease.

Heterogeneity of enhancement kinetics in dynamic contrast-enhanced MRI and implication of distant metastasis in invasive breast cancer

AIM

To investigate the heterogeneity of enhancement kinetics for breast tumour in order to demonstrate the predictive power of dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) features for distant metastasis (DM) in invasive breast cancer.

MATERIALS AND METHODS

Time-signal intensity curve (TIC) patterns from 128 patients with invasive breast cancer were analysed by a pixel-based DCE-MRI analysis. This MRI technique enabled pixels with varying TIC patterns (persistent, plateau, washout and non-enhancement) to be categorised semi-automatically and the percentage of different TIC patterns in each breast tumour to be calculated. The percentage of TIC patterns was compared between the DM and non-DM groups. DM-free survival was estimated using Kaplan-Meier survival analysis.

RESULTS

This study demonstrated a larger percentage of persistent TIC and non-enhancement TIC was associated with DM in invasive breast cancer. The cut-off values of persistent TIC and non-enhancement TIC were 22.5% and 2.5%. Combining TIC patterns and traditional predictors (tumour size and axillary lymph node status) can improve the prediction efficiency. The multivariable model yielded an area under the receiver operating characteristic curve (AUC) of 0.87 with 0.70 sensitivity and 0.87 specificity in leave-one-out cross-validation (LOOCV). These predictors showed significant differences in DM-free survival by Kaplan-Meier analysis.

CONCLUSION

This study shows that breast tumours with higher heterogeneity are more likely to metastasise, and pixel-based TIC analysis has utility in predicting distant metastasis of invasive breast cancer.

Immunohistochemical index prediction of breast tumor based on multi-dimension features in contrast-enhanced ultrasound

Breast cancer is the leading killer of Chinese women. Immunohistochemistry index has great significance in the treatment strategy selection and prognosis analysis for breast cancer patients. Currently, histopathological examination of the tumor tissue through surgical biopsy is the gold standard to determine immunohistochemistry index. However, this examination is invasive and commonly causes discomfort in patients. There has been a lack of noninvasive method capable of predicting immunohistochemistry index for breast cancer patients. This paper proposes a machine learning method to predict the immunohistochemical index of breast cancer patients by using noninvasive contrast-enhanced ultrasound. A total of 119 breast cancer patients were included in this retrospective study. Each patient implemented the pathological examination of immunohistochemical expression and underwent contrast-enhanced ultrasound imaging of breast tumor. The multi-dimension features including 266 three-dimension features and 837 two-dimension dynamic features were extracted from the contrast-enhanced ultrasound sequences. Using the machine learning prediction method, 21 selected multi-dimension features were integrated to generate a model for predicting the immunohistochemistry index noninvasively. The immunohistochemical index of human epidermal growth factor receptor-2 (HER2) was predicted based on multi-dimension features in contrast-enhanced ultrasound sequence with the sensitivity of 71%, and the specificity of 79% in the testing cohort. Therefore, the noninvasive contrast-enhanced ultrasound can be used to predict the immunohistochemical index. To our best knowledge, no studies have been reported about predicting immunohistochemical index by using contrast-enhanced ultrasound sequences for breast cancer patients. Our proposed method is noninvasive and can predict immunohistochemical index by using contrast-enhanced ultrasound in several minutes, instead of relying totally on the invasive and biopsy-based histopathological examination. Graphical abstract Immunohistochemical index prediction of breast tumor based on multi-dimension features in contrast-enhanced ultrasound.

Cytological Grading of Breast Tumors-The Human and Canine Perspective

Human breast cancers (HBCs) are one of the leading causes of global cancer death among women. Domesticated canines are the most affected domestic species with a prevalence rate of breast cancer more than three times in women. While the human cancer patients receive substantial diagnostic and treatment facilities, inadequacy in canine cancer care, calls for greater attention. Fine Needle Aspiration Cytology (FNAC) is comparatively simple, quick, and easily reproducible technique, which aids in pre-surgical diagnosis. In humans, FNAC has a standard protocol, the Robinson's grading system, which has high correlation with the established histological grading system of Scarff Bloom- Richardson. However, Canine Mammary Tumors (CMTs), which are known to be similar to HBCs in biological behavior and gene expressions, still bank on the histopathological methods for diagnostic purposes. This review sheds light on various factors that could be considered for developing a standard FNAC technique for CMT grading and analyzes its future perspectives.

The Relationship Between MRI Findings and Molecular Subtypes in Women With Breast Cancer

OBJECTIVE

To determine the preoperative MRI findings of patients with breast cancer according to molecular subtypes.

MATERIALS AND METHODS

MRI findings of women diagnosed with breast cancer in our department between January 2013 and June 2017 who had preoperative breast MRI examinations were evaluated and histopathological findings were recorded retrospectively. The findings were classified according to the BI-RADS MRI classification by three radiologists. Correlations of MRI findings with the molecular subtypes were evaluated using Chi-square and t-tests.

RESULTS

Among 234 lesions in a total of 224 cases diagnosed with breast cancer, subtypes of breast cancer as following: Luminal (162 cases, 69%), triple negative (39 cases, 17%) and HER2 positive (33 cases, 14%), respectively. Lesions of patients with luminal, triple negative and HER2 positive invasive ductal cancer were round or lobular in shape (9.9%, 42.9%, 20.7%), had high/very high intratumoral T2 signal intensity (24.8%, 54.2%, 31%) and rim enhancement pattern (9.2%, 51.4%, 24.1%), respectively. The difference between the triple negative cases and the other subtypes was statistically significant (p < 0.05).

CONCLUSION

One of the most important factors that determine the prognosis and treatment in breast cancer is the molecular subtype of the tumor. Morphologic findings of MRI can be a useful tool for differentiating triple negative breast cancer from other subtypes.

Evaluation of Estrogen and Progesterone Receptors and Her-2 Expression with Grading in the Fine-needle Aspirates of Patients with Breast Carcinoma

Background:

There has been a limited literature with regards to comparison between the pre-operative hormonal/Her-2 neu assessment by immunostaining on fine-needle aspiration (FNA) versus core needle biopsies (CNBs) and their correlation with grading of breast carcinoma.

Materials and Methods:

Two hundred fifty FNAs and 201 CNBs from 252 patients with breast carcinoma were subjected immunocytochemical/histochemical (ICC/IHC) staining along with the grading by the Robinson cytologic and modified Scarff-Bloom-Richardson scoring systems, respectively. Depending on the material adequacy, IHC was also performed on cell blocks. Sensitivity, specificity, and predictive values of ICC were calculated. The kappa statistics was performed to see the power of the study. Cytologic versus histologic gradings were compared and analysed by percentage analysis.

Results:

Sensitivity of ICC on FNAs for ER, PR, and Her-2neu was 49%, 28.8%, and 46%, respectively, while specificity was 84.5%, 90.6%, and 86.6%, respectively, with a fair agreement on kappa statistics. Her-2neu positivity on CNB versus FNA had a moderate agreement. Her-2neu staining of 3+ was seen in most of the Grade-2 tumours on FNA.

Conclusions:

Fairly reliable results on grading and hormonal/Her-2neu status are possible when ICC is performed on qualitatively superior FNA material. This is particularly useful in the management of patients in certain settings like inoperable cases.

Nomograms for preoperative prediction of axillary nodal status in breast cancer

Background

Axillary staging in patients with breast cancer and clinically node‐negative disease is performed by sentinel node biopsy (SLNB). The aim of this study was to integrate feasible preoperative variables into nomograms to guide clinicians in stratifying treatment options into no axillary staging for patients with non‐metastatic disease (N0), SLNB for those with one or two metastases, and axillary lymph node dissection (ALND) for patients with three or more metastases.

Methods

Patients presenting to Skåne University Hospital, Lund, with breast cancer were included in a prospectively maintained registry between January 2009 and December 2012. Those with a preoperative diagnosis of nodal metastases were excluded. Patients with data on hormone receptor status, human epidermal growth factor receptor 2 and Ki‐67 expression were included to allow grouping into surrogate molecular subtypes. Based on logistic regression analyses, nomograms summarizing the strength of the associations between the predictors and each nodal status endpoint were developed. Predictive performance was assessed using the area under the receiver operating characteristic (ROC) curve. Bootstrap resampling was performed for internal validation.

Results

Of the 692 patients eligible for analysis, 248 were diagnosed with node‐positive disease. Molecular subtype, age, mode of detection, tumour size, multifocality and vascular invasion were identified as predictors of any nodal disease. Nomograms that included these predictors demonstrated good predictive abilities, and comparable performances in the internal validation; the area under the ROC curve was 0·74 for N0versus any lymph node metastasis, 0·70 for one or two involved nodes versusN0, and 0·81 for at least three nodes versus two or fewer metastatic nodes.

Conclusion

The nomograms presented facilitate preoperative decision‐making regarding the extent of axillary surgery.

Defines need for staging?

Characterization of HER2 gene amplification heterogeneity in invasive and in situ breast cancer using bright-field in situ hybridization

The aims of this study were to evaluate and compare the HER2 gene amplification status in invasive and adjacent in situ breast carcinoma, using bright-field in situ hybridization, and to document the possible presence of HER2 genetic heterogeneity (HER2-GH) in both components. A cohort of 100 primary invasive carcinomas (IC) associated with carcinoma in situ (CIS) were evaluated for HER2 gene amplification by SISH according to the 2013 ASCO/CAP HER2 guideline. A second cohort of all the cases with HER2-GH since the introduction of the updated ASCO/CAP HER2 guideline was also characterized, and an evaluation of the HER2 gene amplification in the CIS component, if present, was also done. In the first cohort, the HER2 amplification in the IC was negative in 87% of the cases and positive in 13% of the cases, without the presence of HER2-GH. All the cases had an associated CIS with the same HER2 status as IC, with four cases of CIS presenting HER2-GH. In the CIS, we observed a significant relationship of HER2 gene amplification with high nuclear grade. In the four cases with HER2-GH in CIS, two cases presented HER2 gene amplification in the IC. The second cohort included 12 cases with HER2-GH in a total of 1243 IC cases (0.97%). Additionally, we identified two cases associated with non-amplified CIS. HER2-GH is a rare event in IC and can already be present in CIS, not being an important step in the acquisition of invasive features.

Survival is associated with complete response on MRI after neoadjuvant chemotherapy in ER-positive HER2-negative breast cancer

Background

Pathological complete remission (pCR) of estrogen receptor (ER)-positive/human epidermal growth factor receptor 2 (HER2)-negative breast cancer is rarely achieved after neoadjuvant chemotherapy (NAC). In addition, the prognostic value of pCR for this breast cancer subtype is limited. We explored whether response evaluation by magnetic resonance imaging (MRI) is associated with recurrence-free survival after NAC in ER-positive/HER2-negative breast cancer.

Methods

MRI examinations were performed in 272 women with ER-positive/HER2-negative breast cancer before, during and after NAC. MRI interpretation included lesion morphology at baseline, changes in morphology and size, and contrast uptake kinetics. These MRI features, clinical characteristics and final pathology were correlated with recurrence-free survival.

Results

The median follow up time was 41 months. There were 35 women with events, including 19 breast-cancer-related deaths. On multivariable analysis, age younger than 50 years (hazard ratio (HR) = 2.55, 95 % confidence interval (CI) 1.3, 5.02, p = 0.007), radiological complete response after NAC (HR = 14.11, CI 1.81, 1818; p = 0.006) and smaller diameters of washout/plateau enhancement at MRI after NAC (HR = 1.02, CI 1.00, 1.04, p = 0.036) were independently associated with best recurrence-free survival. Pathological response was not significant; HR = 2.12, CI 0.86, 4.64, p = 0.096.

Conclusions

MRI after NAC in ER-positive/HER2-negative tumors may be predictive of recurrence-free survival. A radiological complete response at MRI after NAC is associated with an excellent prognosis.

Metabolomics of Breast Cancer Using High-Resolution Magic Angle Spinning Magnetic Resonance Spectroscopy: Correlations with 18F-FDG Positron Emission Tomography-Computed Tomography, Dynamic Contrast-Enhanced and Diffusion-Weighted Imaging MRI

Purpose

Our goal in this study was to find correlations between breast cancer metabolites and conventional quantitative imaging parameters using high-resolution magic angle spinning (HR-MAS) magnetic resonance spectroscopy (MRS) and to find breast cancer subgroups that show high correlations between metabolites and imaging parameters.

Materials and methods

Between August 2010 and December 2013, we included 53 female patients (mean age 49.6 years; age range 32–75 years) with a total of 53 breast lesions assessed by the Breast Imaging Reporting and Data System. They were enrolled under the following criteria: breast lesions larger than 1 cm in diameter which 1) were suspicious for malignancy on mammography or ultrasound (US), 2) were pathologically confirmed to be breast cancer with US-guided core-needle biopsy (CNB) 3) underwent 3 Tesla MRI with dynamic contrast-enhanced (DCE) and diffusion-weighted imaging (DWI) and positron emission tomography-computed tomography (PET-CT), and 4) had an attainable immunohistochemistry profile from CNB. We acquired spectral data by HR-MAS MRS with CNB specimens and expressed the data as relative metabolite concentrations. We compared the metabolites with the signal enhancement ratio (SER), maximum standardized FDG uptake value (SUV max), apparent diffusion coefficient (ADC), and histopathologic prognostic factors for correlation. We calculated Spearman correlations and performed a partial least squares-discriminant analysis (PLS-DA) to further classify patient groups into subgroups to find correlation differences between HR-MAS spectroscopic values and conventional imaging parameters.

Results

In a multivariate analysis, the PLS-DA models built with HR-MAS MRS metabolic profiles showed visible discrimination between high and low SER, SUV, and ADC. In luminal subtype breast cancer, compared to all cases, high SER, ADV, and SUV were more closely clustered by visual assessment. Multiple metabolites were correlated with SER and SUV in all cases. Multiple metabolites showed correlations with SER and SUV in the ER positive, HER2 negative, and Ki-67 negative groups.

Conclusion

High levels of PC, choline, and glycine acquired from HR-MAS MRS using CNB specimens were noted in the high SER group via DCE MRI and the high SUV group via PET-CT, with significant correlations between choline and SER and between PC and SUV. Further studies should investigate whether HR-MAS MRS using CNB specimens can provide similar or more prognostic information than conventional quantitative imaging parameters.

Combined Use of Unguided FNA and CNB Increases the Diagnostic Accuracy for Palpable Breast Lesions

BACKGROUND

Obtaining nonsurgical precise diagnosis of a palpable breast lesion is of paramount importance. Both core needle biopsy (CNB) and fine needle aspiration (FNA) are validated techniques used for this purpose. In this study, we compared the accuracy of both methods and explored whether combining both tests adds significant diagnostic value, and for the first time, we tested the concordance of tumor grading in parallel biopsies with reference to surgical excision (SE).

METHODS

Patients underwent concurrent unguided FNA and CNB followed by SE were retrospectively recruited. Chi-square was used to compare the accuracy of malignancy detection, and tumor grade agreement was calculated using kappa (k) statistical test with reference to SE findings.

RESULTS

All patients were females (n: 170). The median age was 45 years. Excluding 18 cases which had inadequate FNA, accuracy of FNA and CNB was 86.2% and 79.6%; respectively. Accuracy was 94.1% when we considered both tests together for any positive result. For tumor grading, the agreement was 91.6% for CNB and 98.8% for FNA.

CONCLUSION

Diagnostic strength was comparable for both FNA and CNB, slightly more favorable for the former. Combination of both tests significantly minimized missing cases as false negative. When available, it is worthy to grade malignant FNA samples. Diagn. Cytopathol. 2016;44:578-581. © 2016 Wiley Periodicals, Inc.

Concordance between core needle biopsy and surgical specimen for oestrogen receptor, progesterone receptor and human epidermal growth factor receptor 2 status in breast cancer

INTRODUCTION

This study aimed to analyse the concordance rate, sensitivity, specificity, positive predictive value (PPV) and negative predictive value of core needle biopsy (CNB) and subsequent surgical specimen (SS) in assessing levels of oestrogen receptor (ER), progesterone receptor (PgR) and human epidermal growth factor receptor 2 (HER2/neu). It also evaluated the revised American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) guidelines for ER/PgR positivity.

METHODS

We analysed the breast cancer database of KK Women's and Children's Hospital, Singapore, from 1 June 2005 to 30 December 2012. Invasive breast cancer patients who had CNB and subsequent SS were included.

RESULTS

A total of 560 patients were included. The concordance of ER, PgR and HER2/neu positivity between CNB and SS was 96.1%, 89.1% and 96.8%, respectively. When the 'ER ≥ 10% positive' group was compared with the 'ER ≥ 1% positive' group, specificity increased from 79.7% to 92.5% and PPV increased from 93.9% to 97.5%. When the 'PgR ≥ 10% positive' group was compared with the 'PgR ≥ 1% positive' group, specificity increased from 84.2% to 89.3% and PPV improved from 89.7% to 92.9%. The revised ASCO/CAP guidelines decreased discordant results by > 50% for ER and by 18.2% for PgR.

CONCLUSION

CNB has high concordance with SS in the evaluation of the molecular profile of invasive breast cancer. Thus, molecular evaluation does not need to be repeated with SS except for ER-, PgR- and HER2/neu-negative CNB results. The revised ASCO/CAP guidelines resulted in more precise ER and PgR status on CNB.

Dual-Modality Photoacoustic and Ultrasound Imaging System for Noninvasive Sentinel Lymph Node Detection in Patients with Breast Cancer

The detection of regional lymph node metastases is important in cancer staging as it guides the prognosis of the patient and the strategy for treatment. Sentinel lymph node biopsy (SLNB) is an accurate, less invasive alternative to axillary lymph node dissection. The sentinel lymph node hypothesis states that the pathological status of the axilla can be accurately predicted by determining the status of the first lymph nodes that drain from the primary tumor. Physicians use radio-labeled sulfur colloid and/or methylene blue dye to identify the SLN, which is most likely to contain metastatic cancer cells. However, the surgical procedure causes morbidity and associated expenses. To overcome these limitations, we developed a dual-modality photoacoustic and ultrasonic imaging system to noninvasively detect SLNs based on the accumulation of methylene blue dye. Ultimately, we aim to guide percutaneous needle biopsies and provide a minimally invasive method for axillary staging of breast cancer.

Impact of preoperative evaluation of tumour grade by core needle biopsy on clinical risk assessment and patient selection for adjuvant systemic treatment in breast cancer

BACKGROUND

Histological characteristics are important when making a decision on adjuvant systemic treatment in breast cancer. Preoperative assessments of core needle biopsy (CNB) specimens are becoming increasingly relevant as novel minimally invasive ablative techniques are introduced, because a surgical specimen is no longer obtained with these methods. The clinical impact of potential underestimation of tumour grade on preoperative CNB on clinical decision-making was evaluated.

METHODS

Histological tumour grade was reassessed on CNB and resection specimens from consecutive invasive ductal carcinomas diagnosed between 2010 and 2013. For each patient, the indication for systemic therapy was assessed, based on either CNB or surgical excision, in combination with clinical characteristics and imaging findings. The clinical impact of discordance between tumour grade on CNB versus the resection specimen was assessed.

RESULTS

The analysis included 213 invasive ductal carcinomas in 199 patients. Discordance in tumour grade between CNB and the resection specimen was observed in 64 (30.0 per cent) of 213 tumours (κ = 0.53, 95 per cent c.i. 0.43 to 0.63). A decision on adjuvant treatment based on CNB would have resulted in overtreatment in seven (3.5 per cent) and undertreatment in three (1.5 per cent) of 199 patients. In the undertreated patients, incorrect omission of adjuvant systemic treatment would have increased the predicted 10-year mortality rate by 2.6-5.2 per cent and 10-year recurrence rate by 8.2-15.3 per cent based on the online risk assessment tool Adjuvant!

CONCLUSION

The substantial discordance in tumour grading between CNB and resection specimens from breast cancer affects the indication for adjuvant therapy in only a small minority of patients with invasive ductal carcinoma. Assessment of tumour grade by CNB is feasible and accurate for the planning of postoperative treatment.

Pathologic response prediction to neoadjuvant chemotherapy utilizing pretreatment near-infrared imaging parameters and tumor pathologic criteria

Introduction

The purpose of this study is to develop a prediction model utilizing tumor hemoglobin parameters measured by ultrasound-guided near-infrared optical tomography (US-NIR) in conjunction with standard pathologic tumor characteristics to predict pathologic response before neoadjuvant chemotherapy (NAC) is given.

Methods

Thirty-four patients’ data were retrospectively analyzed using a multiple logistic regression model to predict response. These patients were split into 30 groups of training (24 tumors) and testing (12 tumors) for cross validation. Tumor vascularity was assessed using US-NIR measurements of total hemoglobin (tHb), oxygenated (oxyHb) and deoxygenated hemoglobin (deoxyHb) concentrations acquired before treatment. Tumor pathologic variables of tumor type, Nottingham score, mitotic index, the estrogen and progesterone receptors and human epidermal growth factor receptor 2 acquired before NAC in biopsy specimens were also used in the prediction model. The patients’ pathologic response was graded based on the Miller-Payne system. The overall performance of the prediction models was evaluated using receiver operating characteristic (ROC) curves. The quantitative measures were sensitivity, specificity, positive and negative predictive values (PPV and NPV) and the area under the ROC curve (AUC).

Results

Utilizing tumor pathologic variables alone, average sensitivity of 56.8%, average specificity of 88.9%, average PPV of 84.8%, average NPV of 70.9% and average AUC of 84.0% were obtained from the testing data. Among the hemoglobin predictors with and without tumor pathological variables, the best predictor was tHb combined with tumor pathological variables, followed by oxyHb with pathological variables. When tHb was included with tumor pathological variables as an additional predictor, the corresponding measures improved to 79%, 94%, 90%, 86% and 92.4%, respectively. When oxyHb was included with tumor variables as an additional predictor, these measures improved to 77%, 85%, 83%, 83% and 90.6%, respectively. The addition of tHb or oxyHb significantly improved the prediction sensitivity, NPV and AUC compared with using tumor pathological variables alone.

Conclusions

These initial findings indicate that combining widely used tumor pathologic variables with hemoglobin parameters determined by US-NIR may provide a powerful tool for predicting patient pathologic response to NAC before the start of treatment.

Trial registration

ClincalTrials.gov ID: NCT00908609 (registered 22 May 2009)

Electronic supplementary material

The online version of this article (doi:10.1186/s13058-014-0456-0) contains supplementary material, which is available to authorized users.

Breast cancer characteristics-comparison of preoperative and postoperative values

Breast cancer characteristics obtained at the time of diagnosis are important for setting the basic strategy of the treatment. Reliability of preoperative investigation differs for various features of the disease. The aim of this study was to ascertain the agreements and differences between preoperative and postoperative values. This retrospective study analyzed the results of 617 women with primary surgery of the breast and axilla. Cohen's kappa coefficient has been employed to measure the degree of agreement between preoperative and postoperative values. Substantial or "almost perfect" agreement has been documented for the histological type of the tumors, their histopathological grade, proliferation index Ki67, as well as for estrogen, progesterone, and HER-2/neu receptors. Substantial differences exist between preoperative and postoperative diagnoses of invasiveness of the tumor, determination of the size of the tumors, and the number of tumor foci. Preoperative imaging and clinical examination of lymph nodes exhibited unacceptably high false negative rates. Heterogeneity of breast cancer cell population, methodology of histology examinations, and insufficient imaging of lymph nodes are the major limitations precluding satisfactory accuracy of preoperative diagnosis. Preoperatively diagnosed in situ carcinomas, as well as multifocal lesions, were the most often sources of diagnostic failures.

Mitotic figure counts are significantly overestimated in resection specimens of invasive breast carcinomas

Several authors have demonstrated an increased number of mitotic figures in breast cancer resection specimen when compared with biopsy material. This has been ascribed to a sampling artifact where biopsies are (i) either too small to allow formal mitotic figure counting or (ii) not necessarily taken form the proliferating tumor periphery. Herein, we propose a different explanation for this phenomenon. Biopsy and resection material of 52 invasive ductal carcinomas was studied. We counted mitotic figures in 10 representative high power fields and quantified MIB-1 immunohistochemistry by visual estimation, counting and image analysis. We found that mitotic figures were elevated by more than three-fold on average in resection specimen over biopsy material from the same tumors (20±6 vs 6±2 mitoses per 10 high power fields, P=0.008), and that this resulted in a relative diminution of post-metaphase figures (anaphase/telophase), which made up 7% of all mitotic figures in biopsies but only 3% in resection specimen (P<0.005). At the same time, the percentages of MIB-1 immunostained tumor cells among total tumor cells were comparable in biopsy and resection material, irrespective of the mode of MIB-1 quantification. Finally, we found no association between the size of the biopsy material and the relative increase of mitotic figures in resection specimen. We propose that the increase in mitotic figures in resection specimen and the significant shift towards metaphase figures is not due to a sampling artifact, but reflects ongoing cell cycle activity in the resected tumor tissue due to fixation delay. The dwindling energy supply will eventually arrest tumor cells in metaphase, where they are readily identified by the diagnostic pathologist. Taken together, we suggest that the rapidly fixed biopsy material better represents true tumor biology and should be privileged as predictive marker of putative response to cytotoxic chemotherapy.

Invasive ductal carcinoma of the breast: correlation between tumor grade determined by ultrasound-guided core biopsy and surgical pathology

OBJECTIVE

The purpose of this article is to evaluate the concordance between tumor grade found on ultrasound-guided core biopsies of invasive ductal carcinomas of the breast and subsequent excision specimens.

MATERIALS AND METHODS

We retrospectively studied 300 consecutive invasive ductal carcinomas (274 women) that were biopsied under sonographic guidance, using 14-gauge core needles exclusively, and that were subsequently excised surgically. A minimum of four cores were taken per lesion. Core biopsy grades were compared with final surgical grades (reference standard). Tumor grade was assigned using the standard modified Scarff-Bloom-Richardson system. The agreement rate was expressed in percentages and in kappa statistics; the rates of overestimation and underestimation were also assessed. The correlation between tumor size (small, ≤ 0.5 cm; medium, 0.6-2.4 cm; and large, ≥ 2.5 cm) and agreement rate was also evaluated.

RESULTS

The overall agreement between core biopsy and surgical pathology grade was 69% (simple κ = 0.46; 95% CI, 0.36-0.54). Agreement by biopsy grade was 86% (55/64) for grade 3, 66% (118/180) for grade 2, and 55% (23/42) for grade 1. Core biopsy underestimated 24% (70/286) and overestimated 7% (20/286) of the lesions. When discordant, core biopsy differed from excision by no more than one grade. Large tumors were more likely to show underestimation rather than overestimation when discordant (rate of underestimation, 92% for large, 81% for medium, and 33% for small tumors; p < 0.0031).

CONCLUSION

Ultrasound-guided core biopsy accurately predicts high-grade breast tumors but is moderately accurate for lower-grade lesions. Large tumor size negatively impacts the accuracy of tumor grade found on biopsy and is associated with underestimation.

Breast cancer: assessing response to neoadjuvant chemotherapy by using US-guided near-infrared tomography

PURPOSE

To assess initial breast tumor hemoglobin (Hb) content before the initiation of neoadjuvant chemotherapy, monitor the Hb changes at the end of each treatment cycle, and correlate these findings with tumor pathologic response.

MATERIALS AND METHODS

The HIPAA-compliant study protocol was approved by the institutional review boards of both institutions. Written informed consent was obtained from all patients. Patients who were eligible for neoadjuvant chemotherapy were recruited between December 2007 and May 2011, and their tumor Hb content was assessed by using a near-infrared imager coupled with an ultrasonography (US) system. Thirty-two women (mean age, 48 years; range, 32-82 years) were imaged before treatment, at the end of every treatment cycle, and before definitive surgery. The patients were graded in terms of their final pathologic response on the basis of the Miller-Payne system as nonresponders and partial responders (grades 1-3) and near-complete and complete responders (grades 4 and 5). Tumor vascularity was assessed from total Hb (tHb), oxygenated Hb (oxyHb), and deoxygenated Hb (deoxyHb) concentrations. Tumor vascularity changes during treatment were assessed from percentage tHb normalized to the pretreatment level. A two-sample two-sided t test was used to calculate the P value and to evaluate statistical significance between groups. Bonferroni-Holm correction was applied to obtain the corrected P value for multiple comparisons.

RESULTS

There were 20 Miller-Payne grade 1-3 tumors and 14 grade 4 or 5 tumors. Mean maximum pretreatment tHb, oxyHb, and deoxyHb levels were significantly higher in grade 4 and 5 tumors than in grade 1-3 tumors (P = .005, P = .008, and P = .017, respectively). The mean percentage tHb changes were significantly higher in grade 4 or 5 tumors than in grade 1-3 tumors at the end of treatment cycles 1-3 (P = .009 and corrected P = .009, P = .002 and corrected P = .004, and P < .001 and corrected P < .001, respectively).

DISCUSSION

These findings indicate that initial tumor Hb content is a strong predictor of final pathologic response. Additionally, the tHb changes during early treatment cycles can further predict final pathologic response.

Usefulness of serum CA 15.3 and histopathological prognostic indices in breast cancer

Prognostic factors influence the modality and course of therapy in breast cancer. These include both histopathological and biochemical variables. This study was aimed to find out if any correlation exists between the biochemical tumor marker-serum CA 15.3, and the lymph node staging of Nottingham's Prognostic Index (NPI). It was observed that serum CA 15.3 showed a statistically significant correlation with lymph node staging of NPI. Therefore it is concluded that CA 15.3 can be utilized as a useful prognostic marker, particularly in cases where histopathological variables such as tumor size and grade have been altered by pre-operative chemotherapy.

Triple-negative invasive breast cancer on dynamic contrast-enhanced and diffusion-weighted MR imaging: comparison with other breast cancer subtypes

OBJECTIVES

To determine the MRI features of triple-negative invasive breast cancer (TNBC) on dynamic contrast-enhanced MR imaging (DCE-MRI) and diffusion-weighted MR imaging (DWI) in comparison with ER-positive/HER2-negative (ER+) and HER2-positive cancer (HER2+).

METHODS

A total of 271 invasive cancers in 269 patients undergoing preoperative MRI and surgery were included. Two radiologists retrospectively assessed morphological and kinetic characteristics on DCE-MRI and tumour detectability on DWI. Apparent diffusion coefficient (ADC) values of lesions were measured. Clinical and MRI features of the three subtypes were compared.

RESULTS

Compared with ER+ (n = 119) and HER2+ (n = 94), larger size, round/oval mass shape, smooth mass margin, and rim enhancement on DCE-MRI were significantly associated with TNBC (n = 58; P < 0.0001). On DWI, mean ADC value (× 10(-3) mm(2)/s) of TNBC (1.03) was higher than the mean ADC values for ER+ and HER2+ (0.89 and 0.84; P < 0.0001). There was no difference in tumour detectability (P = 0.099). Tumour size (P = 0.009), mass margin (smooth, P < 0.0001; irregular, P = 0.020), and ADC values (P = 0.002) on DCE-MRI and DWI were independent features of TNBC.

CONCLUSIONS

In addition to the morphological features, higher ADC values on DWI were independently associated with TNBC and could be useful in differentiating TNBC from ER+ and HER2+.

KEY POINTS

• Triple-negative breast cancers (TNBC) lack oestrogen/progesterone receptors and HER2 expression/amplification. • TNBCs are larger, better defined and more necrotic than conventional cancers. • On MRI, necrosis yields high T2-weighted signal intensity and ADCs. • High ADC values can be useful in diagnosing TNBC.

Magnetic resonance imaging response monitoring of breast cancer during neoadjuvant chemotherapy: relevance of breast cancer subtype

PURPOSE

To evaluate the relevance of breast cancer subtypes for magnetic resonance imaging (MRI) markers for monitoring of therapy response during neoadjuvant chemotherapy (NAC).

PATIENTS AND METHODS

MRI examinations were performed in 188 women before and during NAC. MRI interpretation included lesion morphology at baseline, changes in morphology, size, and contrast uptake kinetics (initial and late enhancement). By using immunohistochemistry, tumors were divided into three subtypes: triple negative, human epidermal growth factor receptor 2 (HER2) positive, and estrogen receptor (ER) positive/HER2 negative. Tumor response was assessed dichotomously (ie, presence or absence of residual tumor in the surgical specimen). Complementary, a continuous scale assessment was used (the breast response index [BRI], representing the relative change in tumor stage). Multivariate regression analysis and receiver operating characteristic analysis were employed to establish significant associations.

RESULTS

Residual tumor at pathology was present in 31 (66%) of 47 triple-negative tumors, 23 (61%) of 38 HER2-positive tumors, and 96 (93%) of 103 ER-positive/HER2-negative tumors. Multivariate analysis of residual disease showed significant associations between breast cancer subtype and MRI (area under the curve [AUC], 0.84; P < .001). BRI also showed significant correlation among breast cancer subtype, MRI, and age (Pearson's r = 0.465; P < .001). In subset analysis, this was only significant for triple-negative tumors (P < .001) and HER2-positive tumors (P < .05). Residual tumor after NAC in the triple-negative and HER2-positive group is significantly associated with the change in largest diameter of late enhancement during NAC (AUC, 0.76; P < .001). No associations were found for ER-positive/HER2-negative tumors.

CONCLUSION

MRI during NAC to monitor response is effective in triple-negative or HER2-positive disease but is inaccurate in ER-positive/HER2-negative breast cancer.

Histological grading of breast cancer on needle core biopsy: the role of immunohistochemical assessment of proliferation

Aims

Histological grade assessed on needle core biopsy (NCB) moderately concurs with the grade in the surgical excision specimen (SES) (κ-values between 0.35 and 0.65). A major cause of the discrepancy is underestimation of mitoses in the NCB specimen. The aim was to determine the best method of assessing proliferation on NCB.

Methods and results

Proliferative activity of 101 invasive carcinomas of the breast on NCB and SES was assessed using mitotic counts on routine haematoxylin and eosin (H&E) sections and immunohistochemical markers Mib-1 and phosphorylated histone H3 (PPH3). H&E mitotic count in SES was considered as the gold standard. H&E mitotic count was found to be underestimated on NCB when compared with that in SES (P < 0.001), but no significant difference was detected between NCB and SES regarding Mib-1 (P = 0.13) or PPH3 (P = 0.073). Using receiver–operating characteristic curve, Mib-1 on NCB was found to agree with the gold standard significantly better than routine H&E on NCB.

Conclusions

Immunohistochemical markers in NCB showed better concordance with H&E mitotic count in SES (gold standard) than routine H&E mitotic count in NCB. Further refinement of cut-offs and scoring methods is needed.

Vascular invasion in breast cancer; an overview of recent prognostic developments and molecular pathophysiological mechanisms

Vascular invasion (VI) is an essential step in breast cancer metastasis and the main cause of morbidity and mortality from the disease. Detection of VI in the primary tumour is a marker of metastatic potential. The prognostic value of VI in breast cancer has been known for more than four decades, but its application in clinical practice is still fraught with difficulties due to the limited number of studies conducted on large numbers of well-characterized patients with long-term follow-up. Detection of VI in the primary tumour is currently assessed using sections stained with haematoxylin and eosin, which has some disadvantages. A number of vascular markers have been used to improve detection of VI; however, their sensitivity and specificity, as endothelial markers, vary considerably. In this review we describe the evolution of the prognostic importance of VI and the recent pathomolecular mechanisms that contribute to the ability of breast cancers to invade through vessels, in addition to the types, locations and methods of detection of vascular invasion.

Decreased poly(ADP-ribosyl)ation of CTCF, a transcription factor, is associated with breast cancer phenotype and cell proliferation

PURPOSE

There is compelling evidence of a relationship between poly(ADP-ribosyl)ation and tumorigenesis; however, much less is known about the role of specific targets of poly(ADP-ribosyl)ation in tumor development. Two forms of the multifunctional transcription factor, CTCF, were previously identified: a 130-kDa protein (CTCF-130), characteristic for cell lines, and a 180-kDa protein (CTCF-180), modified by poly(ADP-ribosyl)ation. This study was aimed to investigate differential poly(ADP-ribosyl)ation of CTCF in normal and tumor breast tissues.

EXPERIMENTAL DESIGN

Western blot analysis, mass spectrometry, and immunohistochemical and immunofluorescent stainings were used to characterize CTCF-130 and CTCF-180 in breast cell lines, primary cultures, and normal and tumor breast tissues. The immunoreactivity score was used for CTCF-130 quantification in tissues.

RESULTS

We discovered that only CTCF-180 is detected in the normal breast tissues, whereas both CTCF-130 and CTCF-180 are present in breast tumors. Using an antibody specific for CTCF-130, we observed that 87.7% of breast tumors were positive for CTCF-130. A negative correlation existed between the levels of CTCF-130, tumor stage, and tumor size. Significantly, a transition from CTCF-180 to CTCF-130 was discovered in primary cultures generated from normal breast tissues, indicating a link between CTCF-130 and proliferation. Conversely, the appearance of CTCF-180 was observed following growth arrest in breast cell lines.

CONCLUSIONS

Collectively, our data suggest that the loss of CTCF poly(ADP-ribosyl)ation is associated with cell proliferation and breast tumor development. We propose the use of CTCF-130 as a marker for tumor breast cells and lower levels of CTCF-130 as an indicator of unfavorable prognosis.

Concordance of clinical and molecular breast cancer subtyping in the context of preoperative chemotherapy response

ER, PR and HER2 status in breast cancer are important markers for the selection of drug therapy. By immunohistochemistry (IHC), three major breast cancer subtypes can be distinguished: Triple negative (TN(IHC)), HER2+(IHC) and Luminal(IHC) (ER+(IHC)/HER2-(IHC)). By using the intrinsic gene set defined by Hu et al. five molecular subtypes (Basal(mRNA), HER2+(mRNA), Luminal A(mRNA), Luminal B(mRNA) and Normal-like(mRNA)) can be defined. We studied the concordance between analogous subtypes and their prediction of response to neoadjuvant chemotherapy. We classified 195 breast tumors by both IHC and mRNA expression analysis of patients who received neoadjuvant treatment at the Netherlands Cancer institute for Stage II-III breast cancer between 2000 and 2007. The pathological complete remission (pCR) rate was used to assess chemotherapy response. The IHC and molecular subtypes showed high concordance with the exception of the HER2+(IHC) group. 60% of the HER2+(IHC) tumors were not classified as HER2+(mRNA). The HER2+(IHC)/Luminal A or B(mRNA) group had a low response rate to a trastuzumab-chemotherapy combination with a pCR rate of 8%, while the HER2+(mRNA) group had a pCR rate of 54%. The Luminal A(mRNA) and Luminal B(mRNA) groups showed similar degrees of response to chemotherapy. Neither the PR status nor the endocrine responsiveness index subdivided the ER+(IHC) tumors accurately into Luminal A(mRNA) and Luminal B(mRNA) groups. Molecular subtyping suggests the existence of a HER2+(IHC)/Luminal(mRNA) group that responds poorly to trastuzumab-based chemotherapy. For Luminal(IHC) and triple negative(IHC) tumors, further subdivision into molecular subgroups does not offer a clear advantage in treatment selection.

Surgical specimen can be replaced by core samples in assessment of ER, PR and HER-2 for invasive breast cancer

OBJECTIVE

To compare 14-gauge SCNB (stereotactic core needle biopsy) with surgery and to investigate tissue-heterogeneity of estrogen receptors (ER), progesterone receptors (PR) and human epidermal growth-factor receptor (HER-2) for nonpalpable breast cancers. To determine the number of cores needed for assessment of these factors.

MATERIALS AND METHODS

Cores of 41 invasive cancers were collected in three containers: the 1st into A, the 2nd and 3rd into B and subsequent cores into C. ER, PR and HER-2 were scored by immunohistochemistry and if 2+ or 3+, by chromogenic-in-situ-hybridisation (CISH) for containers and for surgical specimen.

RESULTS

Between SCNB and surgical specimen concordance was 83% (kappa = 0.39) for ER, 88% (kappa = 0.69) for PR and HER-2 and 93% (kappa = 0.63) for HER-2 after CISH. For the most discordant cases, status was positive in cores but negative in surgery: 5/7 for ER (p = 0.459), 5/5 for PR (p = 0.063), and 4/5 for HER-2 (p = 0.375), after CISH 3/3 (p = 0.250), but the difference was not statistically significant. Concordances between containers of cores was 100% (kappa = 1), 85% (kappa = 0.66) and 85% (kappa = 0.66), respectively. With more than three cores, sensitivities of 95%, 100% and 100% were reached.

CONCLUSIONS

SCNB is at least as sensitive as surgery in assessment of ER, PR and HER-2. Three cores are needed for reliable assessment of HER-2 after adding CISH and more than three cores for PR, possibly due to tissue heterogeneity. For ER sensitivity remained lower, 95%, even in multiple cores, therefore ER-negative cases should be further investigated from surgical specimens.

Can core biopsy be used instead of surgical biopsy in the diagnosis and prognostic factor analysis of breast carcinoma?

PURPOSE

The aim of this article was to investigate the efficacy of ultrasonography-guided core needle biopsy and prognostic factor analysis of breast cancer to plan overall treatment strategy.

PATIENTS AND METHODS

A consecutive series of nonpalpable and palpable breast cancers constituted our study group (n= 201 lesions; mean size, 20.4 mm) Mean number of core samples was 3.4. Malignant lesions diagnosed with core biopsy underwent therapeutic surgical excision. Core biopsy and surgical excisions were compared for histologic type, grade, estrogen receptors (ERs), progesterone receptors (PgRs), and c-erbB2 levels. Cutoff values for ER, PgR, and c-erbB2 affecting the management strategy were selected as 10%, 10%, and 50%, respectively.

RESULTS

Eighty-five lesions (42.3%) were malignant in core biopsy (mean size, 18.4 mm). Among these, 11 were inoperable and 13 were surgically excised at other institutions. In 61 lesions, core and surgical excision specimens were evaluated in the same institution (mean tumor size, 18.6 mm; range 6-60 mm). Concordance between the 2 biopsy methods was 85.2% (52 of 61) for histologic type of tumor, 68.8% (33 of 48) for tumor grade, 90% (27 of 30) for ER, 86.7% (26 of 30) for PgR, and 79.3% (23 of 29) for c-erbB2 levels. Appropriate site selection for sampling was indicated to be of paramount importance, especially in determining reliable ER, PgR, and c-erbB2 levels.

CONCLUSION

Core needle biopsy of breast cancer is equally effective compared with surgical biopsy and can be used in overall treatment planning. However, appropriate site selection for sampling should be guaranteed using ultrasonographic guidance.

An overview of assessment of prognostic and predictive factors in breast cancer needle core biopsy specimens

Needle core biopsy (NCB), as part of triple assessment for preoperative evaluation and diagnosis of breast cancer, is now considered as an established, highly accurate method for diagnosing breast cancer that has replaced either fine needle aspiration cytology or excisional biopsy as the initial diagnostic biopsy procedures in many institutions. In addition to its primary role in establishing an accurate histological diagnosis, NCB can potentially provide important additional pathological prognostic information which may be of direct clinical value in certain situations, such as patients being considered for preoperative (neoadjuvant) therapy. With this background in mind we briefly review the current role of NCB in breast cancer diagnosis and then concentrate this review on the usefulness and issues relating to use of this technique in providing accurate, reliable and clinically relevant preoperative prognostic and predictive information in patients with breast cancer.

Detection of Survivin-expressing circulating cancer cells in the peripheral blood of breast cancer patients by a RT-PCR ELISA

Survivin mRNA expression was detected in 69.2%-93.8% of primary breast carcinomas, but is rarely expressed in normal breast tissues and hematopoietic cells. The objective of this study was to investigate the significance that the detection of Survinin-expressing circulating breast cancer cells in the peripheral blood has on clinical outcomes. The detection method was based on a RT-PCR ELISA technique developed in our laboratory. Sixty-seven breast cancer patients in various stages and 135 normal healthy women were investigated. Survivin-expressing circulating cancer cells were detected in the peripheral blood samples from 34 (50.7%) out of 67 breast cancer patients, but not in the healthy women that were used as controls. The presence of Survivin-expressing circulating breast cancer cells was found to be significantly associated with various clinicopathological parameters such as vessel infiltration, histological grade, tumor size, nodal status, ER/PgR status, Her-2 status and clinical stages of the disease (P < 0.01). During a follow-up period of 36 months, 9 out of 11 (81.8%) breast cancer patients that had a positive Survivin-expressing at the time of the initial assay test suffered a relapse of the disease, whereas recurrence was only found in 2 out of 6 (33.3%) breast cancer patients that had a negative Survivin-expression. Thus, the detection of circulating cancer cells expressing Survivin mRNA could provide valuable information for the prediction of metastasis and recurrence of breast cancer.

Mammakarzinomgraduierung an Gewebestanzen

The grading of invasive breast cancers according to Bloom and Richardson (Nottingham modification) provides one of the most important prognostic factors in addition to size and the status of the lymph nodes. Diagnostic reproducibility has been problematic in daily practice as the required criteria for selection and extent of the grading area are frequently not present in the punch biopsies.A total of 346 cases were retrospectively used to compare routine grading from surgical preparations with an equivalently small sample from punch biopsies. In addition, a modified grading of these small samples was developed with Ki-67 immunochemistry and the measurement of core size. In the case of modified grading, 1-3 points were given for Ki-67 and average maximum core diameter. Tubule development was evaluated with 1 or 2 points. A comparison for recurrence free survival and total survival showed significant prognostic differences between 3-5 points (low risk) and 6-8 points (high risk) in uni- and multivariate analyses. The evaluation criteria for Nottingham-Bloom-Richardson grading in a small tissue sample, such as that from a punch biopsy, can hardly be fulfilled. In our series, prognostic value was only found for nodal negative cases. After modification using objective parameters such as nuclear size measurement and Ki-67 proliferation index, a small tissue sample can prove to be of significant prognostic value for nodal negative as well as nodal positive cases.

Preoperative Profiling of Symptomatic Breast Cancer by Diagnostic Core Biopsy

BACKGROUND

Precise preoperative profiling of breast tumors could facilitate fuller consideration of (neo)adjuvant therapies.

METHODS

Diagnostic core biopsy (DCB) accuracy in profiling the primary tumor was prospectively studied in 95 patients with operable breast cancer. The histological type and grade (hematoxylin and eosin staining) and membrane receptor status (semiquantitative immunohistochemistry for estrogen [ER] and progesterone [PR] receptors, as well as Her-2 antigen expression) were assigned by the DCB before surgery. These measures were then compared with those of the definitive surgical specimen available after operation.

RESULTS

DCB correctly ascribed tumor type and grade and ER, PR, and Her-2 receptor status in most cases (correlating exactly in 97.5%, 77%, 68%, 71%, and 60%, respectively) with at least moderate concordance (weighted kappa, >.41). When miscategorized, DCB consistently tended to upscore the receptor stain intensity compared with the surgical specimen (22%, 19%, and 27% had higher ER, PR, and Her-2 categorical scores, respectively). ER H-scores correlated best in specimens that stained strongly (224.4 +/- 3 vs. 215.5 +/- 5) and were significantly higher on DCB in those that stained either moderately (195.6 +/- 8.2 vs. 156.8 +/- 5.1; P < .0001) or weakly (157.1 +/- 24.8 vs. 81.4 +/- 4; P = .02). DCB accurately identified all tumors with clinically important ER and Her-2 expression. Furthermore, it promoted three patients into the therapeutically significant range of ER (n = 1) or Her-2 (n = 2) expression. ER negativity on DCB (n = 25) indicated a high-grade tumor (88%), although 11 (44%) patients also overexpressed Her-2. Significant Her-2 expression (n = 16) on DCB predicted the tumor as being poorly differentiated (80%) and both ER and PR negative (67%).

CONCLUSIONS

DCB accurately profiles clinically relevant measures of primary tumor cell differentiation. It also reliably categorizes patients with regard to (neo)adjuvant therapy before radical surgery is attempted.

Sentinel node biopsy should be supplemented by axillary sampling in patients with small breast cancers

Axillary clearance provides important prognostic information but is associated with significant morbidity. Sentinel node biopsy can provide staging .141 patients with node negative early breast cancers-tumour size less than 1.5 cm measured clinically or by imaging had guided axillary sampling (sentinel lymph node biopsy in combination with axillary sampling). Four node axillary sampling improved the detection rate of axillary node metastases by 13.6% as compared to blue dye sentinel node biopsy alone. Positive sampled nodes strongly indicated the likelihood of further metastatic being revealed by axillary dissection (67%). Negative sampled nodes in combination with a positive sentinel node biopsy were associated with a much lower rate of further nodal involvement in the axillary clearance (8%).

The pathology of breast cancer and the role of the histopathology laboratory

Histopathology plays an important part in determining the treatment strategy for women with breast cancer, with the evaluation of breast specimens determining the surgical and the oncological therapeutic options used. The correct approach to specimens requires integration of clinical and imaging findings. This work is not trivial. It is time-consuming and skilled, and requires (and has in place) safeguards and checks in the form of national audit and quality-control schemes. The pathobiology of breast cancer is diverse, and the current taxonomy, rooted in morphological interpretation, has been underscored by molecular observations, such as the relationship of E-cadherin mutations to lobular carcinomas. Investigation of ductal carcinoma of no special type (NST) reveals covert tumour types, such as those with basal or myoepithelial features, whose distinctive features are only now being widely recognised. With the rise of modern molecular techniques, the demise of diagnostic histopathology has been predicted, but, for now and the intermediate future, the histopathologist remains a key element of the integrated breast-care team.

Biopathologic profile of breast cancer core biopsy: is it always a valid method?

For breast cancer management biopathologic profile and particularly the expression of estrogen receptor (ER) and progesterone receptor (PR) is considered essential. In advanced cases, core biopsy results are the only data available. To evaluate reliability of data, results of ER, PR, MIB1, p53 and c-erbB2 on core biopsy were compared with those on surgical specimens. Results showed a statistically significant concordance for ER and PR in pT1 but not in pT2 tumors, possibly due to breast cancer heterogeneity. MIB1 results were worse with no significant concordance even for pT1 group. There was statistically significant concordance in pT1 and pT2 groups for p53 and c-erbB 2, probably due to the high number of negative cases for these markers. We recommend more core biopsies for larger tumors since core biopsy has a high probability for giving unreliable data in these cases. In conclusion, this study showed that core biopsy has a high probability for not very reliable data in bigger tumors where the results obtained might be the only data available. A higher number of core biopsy is recommended in those cases.

Agreement between preoperative core needle biopsy and postoperative invasive breast cancer histopathology is not dependent on the amount of clinical material obtained

AIMS

To establish the relation between the amount of breast core needle biopsy (CNB) material examined and agreement between preoperative and postoperative histopathology parameters in invasive breast cancer.

METHODS

The CNB and surgical specimen histopathology reports of 113 patients with invasive breast carcinoma were reviewed and the total amount of CNB material examined for each case was determined. Agreement was calculated for tumour type, grade, mitoses, nuclear pleomorphism, and tubule formation. Associations between the amount of CNB material and histopathology agreement before and after surgery were explored using binary logistic regression.

RESULTS

Tumour type and grade agreed in 65.4% and 61.6% of cases, respectively. The components used to calculate grade--nuclear pleomorphism (57.4%), mitoses (59.4%), and tubule formation (55.6%)--agreed slightly less frequently. The proportion of cases with preoperative and postoperative assessments that agreed did not depend on the number of cores collected or the total amount of material examined.

CONCLUSION

Neither tumour type and grade, nor the individual components used to calculate grade agreed consistently between the CNB and surgical specimen. The number of cores collected and the total amount of material reviewed by the pathologist does not influence the likelihood of agreement between preoperative and postoperative histopathology reports.

The diagnosis and management of pre-invasive breast disease: the role of new diagnostic techniques

In recent years we have seen significantly increased use of minimally invasive diagnostic techniques in the management of breast disease. There is wide recognition of fine needle aspiration and core biopsy as the principal diagnostic methods. However, concerns exist regarding their reliability. This article provides a brief overview of the major diagnostic issues related to use of fine needle aspiration, core biopsy and ductal lavage. It summarizes areas of use for each technique, outlines the main diagnostic pitfalls and their causes, and provides a perspective on future developments in the field.

Issues in the interpretation of breast core biopsies

Core biopsies are now widely used for the nonoperative diagnosis of breast masses and microcalcifications and have replaced fine-needle aspiration (FNA) cytology for most lesions in many centers. In the United Kingdom, a scoring system of 5 reporting categories, B1-B5, has been adopted, which is to some extent similar to that used in the interpretation of breast FNA. This article is based on the practice at Charing Cross Hospital, London, which is a major regional breast screening and treatment center covering the West of London area; as well as on a thorough review of the contemporary literature. It begins by discussing issues related to the adoption of the technique and to handling core biopsies, followed by a brief presentation of the reporting categories. The article then deals with some commonly encountered diagnostic problems.

Distribution of p63, a novel myoepithelial marker, in fine-needle aspiration biopsies of the breast: an analysis of 82 samples

BACKGROUND

The presence of myoepithelial cells (MECs) in fine-needle aspiration biopsies (FNAB) of the breast constitute an important criterion used to diagnose benign breast lesions. However, MECs sometimes have a distorted cytomorphology, and most of the previously evaluated myoepithelial markers do not have satisfactory sensitivity and specificity. p63, a recently characterized p53 homolog, is a nuclear transcription factor that is expressed in basal cells of multilayered epithelia and myoepithelial cells of the breast. The authors analyzed the immunocytochemical distribution of p63 in a series of 82 breast FNABs (30 benign lesions and 52 malignant breast lesions).

METHODS

Eighty-two archival, Papanicolaou-stained smears of breast lesions were retrieved from the files of the authors' institutions. Immunocytochemistry was performed according to the streptavidin-biotin-peroxidase complex technique using the antibody 4A4 (against all p63 isoforms). Two pathologists evaluated the distribution of p63 positive cells. Only nuclear reactivity was considered specific.

RESULTS

In benign lesions, p63 decorated the nuclei of MECs in all samples. p63 also stained naked nuclei in fibroadenomas. In malignant lesions, p63 was positive in MECs overlying malignant cell clusters in all 8 samples of ductal carcinoma in situ (DCIS), in 9 of 16 samples of pure invasive carcinomas (IC), and in 16 of 20 samples that contained both DCIS and IC. In 18 samples (36%), a variable population of p63 positive, malignant cells was observed. p63 failed to decorate stromal, neural, adipocytic, and smooth muscle cells in all samples.

CONCLUSIONS

p63 is a reliable nuclear marker of MECs in breast aspirates. Regardless of the fact that variable proportions of p63 positive, malignant cells were observed in 36% of breast carcinoma aspirates, p63 may be a useful adjunct antibody to confirm the presence of MECs in FNABs of benign breast lesions.

Surgeon-controlled ultrasound-guided core biopsies in the breast--a prospective study and a new use for surgeons in the clinic

AIMS

This study was to assess the accuracy of a surgeon performing ultrasound-guided core biopsies of the breast.

METHODS

A prospective audit was carried out of 555 patients who underwent an ultrasound-guided core biopsy for a discrete solid mass [under 30 mm maximum diameter] by a single surgeon. The surgeon controlled the core biopsy needle and an ultrasonographer or radiologist provided the imaging with ultrasound.

RESULTS

The accuracy of the surgeon in sampling the lesions [n = 555 core biopsies] was independent of the size of the lesion. This saved 272 patients having unnecessary surgery for a benign lesion.

CONCLUSION

The practical involvement by the surgeon in breast ultrasound and performing core biopsies has reduced pressure on the breast radiologists, reduced the number of diagnostic surgical open biopsies and made the clinic more interesting for the surgeon. With increased surgical confidence in breast ultrasound, most small and impalpable cancers have pre-operative skin marking rather than X-ray wire localization prior to undergoing wide local excision. Trainee breast surgeons should be encouraged to learn breast ultrasound and core biopsies.

Correlation of histologic prognostic factors in core biopsies and therapeutic excisions of invasive breast carcinoma

Breast core biopsy is one of the major nonoperative methods of diagnosis. Increasingly, there is also a need to provide prognostic data to facilitate timely patient management. We present the results from 500 patients with invasive breast carcinoma, who underwent core biopsy followed by a therapeutic surgical procedure. Grade and type of the invasive and in situ carcinoma, together with the presence or absence of vascular invasion, were determined in both biopsy and definitive surgical excision and the results compared. There was 67% agreement with overall grade (kappa value 0.48), with scores for tubule formation, pleomorphism, and mitotic scoring achieving values of 82%, 73%, and 58%, respectively. Only 60% of grade 1 and 2 carcinomas showed concordance, but 84% of grade 3 tumors showed agreement between core and excision results. Tumor typing, vascular invasion, and grading of ductal carcinoma in situ had agreement values of 74%, 69%, and 65%, respectively. The major problem with assessing prognostic factors on needle biopsy specimens is undersampling of the most informative areas. However, in those patients in whom preoperative assessment of prognostic factors is most likely to be beneficial, i.e., those with grade 3 carcinomas, a high level of agreement was achieved in this large study.

p63 Staining of myoepithelial cells in breast fine needle aspirates: a study of its role in differentiating in situ from invasive ductal carcinomas of the breast

AIMS

One of the limitations of fine needle aspiration biopsy (FNAB) of the breast is in distinguishing invasive carcinoma (IDC) from ductal carcinoma in situ (DCIS). It has been proposed that the presence of myoepithelial cells overlying epithelial malignant cell clusters suggests DCIS. However, the recognition of myoepithelial cells in aspirates may be difficult. The aim of this study was to investigate a new nuclear myoepithelial cell marker, p63, a p53 homologue nuclear transcription factor, in a series of breast FNABs in an attempt to distinguish IDC from DCIS.

METHODS

Papanicolaou stained smears from eight cases of pure DCIS and 15 cases of pure IDC with a histologically confirmed diagnosis were submitted to immunocytochemical analysis using the antibody 4A4 against p63. Two pathologists evaluated the presence of p63 positive cells overlying malignant cell clusters and admixed with malignant cells. The frequency of p63 positive cells in DCIS and IDC was compared using Fisher's exact test.

RESULTS

p63 consistently stained the nuclei of myoepithelial cells, either overlying malignant cell clusters and/or admixed with malignant cells. p63 positive myoepithelial cells were seen in all DCIS cases and in nine of the 15 cases of IDC (p = 0.0375). In eight cases (three DCIS and five IDC), scattered p63+ epithelial malignant cells were seen.

CONCLUSIONS

Although p63 positive myoepithelial cells are found more frequently in DCIS cases, their presence cannot be used as a criterion to rule out invasion in breast FNABs because they are present in up to 60% of invasive cases.

Quantitative analysis of human kallikrein gene 14 expression in breast tumours indicates association with poor prognosis

KLK14 (formerly known as KLK-L6) is a recently identified member of the human kallikrein gene family. This family harbours several genes aberrantly expressed in various cancers as well as established (PSA/hK3, hK2) and potential (hK6, hK10) cancer markers. Similar to other kallikrein genes, KLK14 was found to be regulated by steroid hormones, particularly androgens and progestins, in breast and ovarian cancer cell lines. Preliminary studies indicated that KLK14 is differentially expressed in breast, ovarian, prostatic and testicular tumours. Given the above, we determined the prognostic significance of KLK14 expression in breast cancer. We studied KLK14 expression in 178 histologically confirmed epithelial breast carcinomas by quantitative reverse transcription-polymerase chain reaction and correlated with clinicopathological variables (tumour stage, grade, histotype etc.) and with outcome (disease-free survival and overall survival), monitored over a median of 76 months. KLK14 mRNA levels ranged from 0 to 1,219 arbitrary units in breast cancer tissues, with a mean+/-s.e. of 136+/-22. An optimal cutoff value of 40.5 arbitrary units was selected, to categorise tumours as KLK14-positive or negative. Higher concentrations of KLK14 mRNA were more frequently found in patients with advanced stage (III) disease (P=0.032). No statistically significant association was found between KLK14 and the other clinicopathological variables. KLK14 overexpression was found to be a significant predictor of decreased disease-free survival (hazard ratio of 2.31, P=0.001) and overall survival (hazard ratio of 2.21, P=0.005). Cox multivariate analysis indicated that KLK14 was an independent prognostic indicator of disease-free survival and overall survival. KLK14 also has independent prognostic value in subgroups of patients with a tumour size </=2 cm and positive nodal, oestrogen receptor and progestin receptor status. We conclude that KLK14 expression, as assessed by quantitative reverse transcription-polymerase chain reaction, is an independent marker of unfavourable prognosis for breast cancer.

Steroid receptor heterogeneity in relation to DNA index in breast cancer: a multiparameter flow cytometric approach on paraffin-embedded tumor samples

Steroid hormone (estrogen and progesterone) receptor (ER and PR) status at the time of breast carcinoma surgery is used as a marker for hormone dependency to guide adjuvant therapy. In a significant number of cases a discrepancy exists between the detected number of hormone receptors and the response to hormonal therapy. One of the explanations for this could be intratumoral heterogeneity. Our objective was to investigate the heterogeneity of steroid hormone receptor expression in breast cancer by using multiparameter flow cytometry (MP-FCM) on routinely processed formalin-fixed, paraffin-embedded tumors. A series of 232 routinely processed breast carcinomas were analyzed using a recently developed technique for the isolation of single cells from paraffin-embedded material. After dewaxing and rehydrating, 50-microm thick sections were heated for 2 hours at 80 degrees C in a citrate solution. Single-cell suspensions were prepared by a short pepsin digestion. The obtained single-cell suspensions were immunostained simultaneously for cytokeratin and ER or PR. Finally, DNA was stained using propidium iodide, after which the samples were analyzed on a flow cytometer. The fractions of ER- and PR-positive cells were determined in the total, as well as the G0 /G1 fraction of the diploid, and in case of nondiploid tumors, also in the G0 /G1 fraction of the aneuploid cell population. Of 232 cases, 88 (38%) were diploid, 38 (16%) were tetraploid, and 106 (46%) were aneuploid. In the diploid tumors the mean fraction of ER- and PR-positive cells was 81% and 76%, respectively. The ER- and PR-positive fractions in the total cytokeratin-positive fraction decreased significantly in the tetraploid (56% and 55%, respectively) and aneuploid tumors (both 47%, p < 0.0001). When analyzing the ER- and PR-positive fractions separately in the diploid and aneuploid cell populations of the nondiploid tumors, it became apparent that the ER and PR status in the diploid fraction of the tumor was significantly higher than in the aneuploid fraction (p < 0.0001). For the tetraploid tumors the mean ER- and PR-positive fractions were 79% and 76%, respectively, in the diploid fraction, and this decreased to 45% in the aneuploid cell subpopulation. In the aneuploid tumors this decrease was even more drastic: in the diploid cell population the ER- and PR-positive fractions were 66% and 62%, while this was 38% and 39% in the aneuploid population. These findings illustrate clearly the existence of a heterogeneous distribution of ER/PR expression in breast cancer, related to the loss of a diploid DNA index. Because of its objective quantification of subfractions within the same tumor, MP-FCM can be regarded as a superior method compared to more conventional techniques such as immunohistochemistry and biochemistry.