Identification of a subtype of poorly differentiated invasive ductal carcinoma of the breast based on vimentin and e-cadherin expression / Identificação de um subtipo pouco diferenciado de carcinoma ductal invasivo de mama, baseado na expressão da vimentina e E-caderina

Abstract Objective The use of molecular markers can identify a subgroup of tumors with distinct recurrence patterns. The present study aimed to characterize the immunohistochemical expression of vimentin (VIM), of E-cadherin (CDH1), and of cytokeratin 5 (CK5) in patients with invasive ductal carcinomas (IDCs). Methods We have constructed a tissuemicroarray (TMA) from87 patients with IDC of the breast. Immunohistochemistry (IHC) was performed to study the expression of estrogen and progesterone receptors (ER and PgR), human epidermal growth factor receptor 2 (HER2), VIM, CDH1, CK5, and Ki67. The tumors were classified as luminal A and B (n = 39), HER2 enriched (n = 25), and triple-negative (TNBC) (n = 23), based on the IHC expression. Results We have observed that luminal A and B tumors lack the VIM+/CDH1-/low phenotype. This phenotype was observed in 16.5% of the HER2+ tumors and in 60% of the TNBC tumors (p = 0.0001). Out of a total of 20 TNBC tumors, the CK5 (basal-like marker) was positive in 11 of them. The VIM+/CDH1-/low phenotype was observed in 5 CK5+ TNBC tumors (45%) and in 7 out of 9 CK5- TNBC tumors (78%) (p = 0.02). The median Ki67 index in the VIM+/CDH1-/low tumors was 13.6 (range: 17.8-45.4) compared with 9.8 (range: 4.1-38.1) in other tumors (p = 0.0007). The presence of lymph nodemetastasis was less frequent in patients with VIM+/CDH1-/low tumors (23% versus 61%; X2 test; p = 0.01). Conclusion Our findings suggest that the expression of VIM and CDH1 can identify a subset of IDCs of the breast with a mesenchymal phenotype associated with poor prognosis, high-grade lesion, and high mitotic index.

Resumo Objetivo O uso de marcadores moleculares pode identificar subtipos tumorais com diferentes taxas de recidiva. O objetivo do presente estudo é caracterizar a expressão imunohistoquímica da vimentina (VIM), da E-caderina (CDH1) e de CK5 em pacientes com carcinoma ductal invasivo (CDI) da mama. Métodos Utilizamos uma matriz de amostras teciduais (TMA, na sigla em inglês) de 87 pacientes com CDI da mama. Para avaliar a expressão dos receptores de estrogênio (RE) e receptores de progesterona (RP), HER2, VIM, CDH1, CK5 e Ki67, utilizamos imunohistoquímica. Os tumores foram classificados como luminal A e B (n = 39), HER2+ (n = 25) e triplo negativo (TNBC) (n = 23). Resultados Foi observado que tumores luminais A e B não expressaram o fenótipo VIM+/CDH1-/low. Este fenótipo foi observado em 16,5% dos tumores HER2+ e em 60% dos tumores TNBC (p = 0,0001). Dos 20 tumores TNBC, a CK5 (marcador de tumor basalóide) foi super expressa em 11 amostras. O fenótipo VIM+/CDH1-/low foi observado em 5 tumores CK5+ TNBC (45%) e em 7 dos 9 tumores CK5- TNBC (78%) (p = 0,02). A expressão média de Ki67 nos tumores VIM+/CDH1-/low foi 13.6 (amplitude de 17,8 a 45,4) comparado com 9,8 (amplitude de 4,1 a 38,1) nos outros tumores (p = 0,0007). A presença demetástase linfonodal foimenor em tumores com fenótipo VIM+/CDH1-/low (23% contra 61%; teste X2; p = 0,01). Conclusão Nossos achados sugerem que a expressão de VIM e CDH1 pode identificar um subtipo de CDI da mama com fenótipo mesenquimal associado a pior prognóstico, lesões de alto grau e alto índice mitótico.

Immunohistochemical profile of high-grade ductal carcinoma in situ of the breast

OBJECTIVE: To determine the frequency of the immunohistochemical profiles of a series of high-grade ductal carcinoma in situ of the breast. METHODS: One hundred and twenty-one cases of high-grade ductal carcinoma in situ, pure or associated with invasive mammary carcinoma, were identified from 2003 to 2008 and examined with immunohistochemistry for estrogen receptor, human epidermal growth factor receptor 2, cytokeratin 5, and epidermal growth factor receptor. The tumors were placed into five subgroups: luminal A, luminal B, HER2, basal-like, and “not classified”. RESULTS: The frequencies of the immunophenotypes of pure ductal carcinoma in situ were the following: luminal A (24/42 cases; 57.1%), luminal B (05/42 cases; 11.9%), HER2 (07/42 cases; 16.7%), basal-like phenotype (00/42 cases; 0%), and “not classified” (06/42 cases; 14.3%). The immunophenotypes of ductal carcinoma in situ associated with invasive carcinoma were the following: luminal A (46/79 cases; 58.2%), luminal B (10/79 cases; 12.7%), HER2 (06/79 cases; 7.6%), basal-like (06/79 cases; 7.6%), and “not classified” (11/79 cases; 13.9%). There was no significant difference in the immunophenotype frequencies between pure ductal carcinoma in situ and ductal carcinoma in situ associated with invasive carcinoma (p>0.05). High agreement was observed in immunophenotypes between both components (kappa=0.867). CONCLUSION: The most common immunophenotype of pure ductal carcinoma in situ was luminal A, followed by HER2. The basal-like phenotype was observed only in ductal carcinoma in situ associated with invasive carcinoma, which had a similar phenotype. .

Expresión de KI-67 como factor pronóstico en las clases moleculares de carcinoma / Ki-67 as prognostic factor in the molecular class of breast carcinoma

Determinar si el índice de proliferación basado en la expresión del antígeno Ki-67 es un factor pronóstico que permite sub-clasificar las clases moleculares de carcinoma de mama. 312 tumores de pacientes del Instituto de Oncología “Dr. Miguel Pérez Carreño” con carcinoma ductal infiltrante diagnosticadas entre 2000 a 2008. Se determinó la clasificación molecular según el perfil de expresión inmunohistoquímico de receptores hormonales y HER2; el índice de Ki-67 se estratificó en bajo (≤14,50%), intermedio (14,51% -25,50%) alto (≥25,51%). Asimismo, se registró edad, grado histológico, estadio clínico y evolución de acuerdo a la supervivencia global e intervalo libre de enfermedad a través de curvas de Kaplan Meier. En la serie, se clasificaron 132 casos (42,31%) como luminal A, 66 (21,15%) como luminal B, 27 (8,65%) como HER2 y 87 (27,88%) como triple negativo. Se observó que existe variación de evolución en cada clase molecular según el índice Ki-67, y se demostró dentro de cada clase que las pacientes con índice alto presentaron menor supervivencia global e intervalo libre de enfermedad, mientras que aquéllas pacientes con índice bajo mostraron mejor pronóstico con mayor supervivencia global e intervalo libre de enfermedad P≤0,05). El índice de Ki-67 permite establecer dentro de cada clase molecular subgrupos de mejor o peor pronóstico, con valores de corte de 14,5% para los luminal A y de 25,51 para los luminal B, HER2 y triple negativo

To determine if the proliferation index based on the Ki-67 antigen’s expression is a prognostic factor in the molecular classes of the breast carcinoma. The study was carried on 312 tumors of patients view in the “Dr. Miguel Pérez Carreño” Oncology Institute with have infiltrating ductal carcinoma of the breast diagnosed between the years 2000 and 2008. The molecular classification was done according to hormonal receptor expression profile by the immunohistochemistry; the Ki-67 index was stratified into low (≤14.50%), intermediate (14.51% - 25.50%) and high (≥25.51%). Likewise the age, the histological grade, the clinical stage, and the evolution by the overall survival and the relapse free-survival through the curve of Kaplan Meier were established. In this group, 132 cases (42.31%) were classified into luminal A, 66 (21.15%) as luminal B, 27 (8.65%) as HER2 and 87 (27.88%) as triple negative. Variation in the evolution was observed in each molecular class according to the Ki-67 index. Therefore it was demonstrated in each class, that patients with high index presented lower overall survival and relapse free survival, whereas those whom had low index exhibited better prognosis with higher overall survival and relapse free survival. The proliferation index of Ki-67 expression allows to establish in each molecular class subgroups with better or worse prognosis, with cut-off values of 14.5 % for luminal A cases and 25.51 for luminal B, HER2 and triple negative

Observer Agreement Using the ACR Breast Imaging Reporting and Data System (BI-RADS)-Ultrasound, First Edition (2003)

OBJECTIVE: This study aims to evaluate the degree of inter- and intraobserver agreement when characterizing breast abnormalities using the Breast Imaging Reporting and Data System (BI-RADS)-ultrasound (US) lexicon, as defined by the American College of Radiology (ACR). MATERIALS AND METHODS: Two hundred ninety three female patients with 314 lesions underwent US-guided biopsies at one facility during a two-year period. Static sonographic images of each breast lesion were acquired and reviewed by four radiologists with expertise in breast imaging. Each radiologist independently evaluated all cases and described the mass according to BI-RADS-US. To assess intraobserver variability, one of the four radiologists reassessed all of the cases one month after the initial evaluation. Inter- and intraobserver variabilities were determined using Cohen's kappa (k) statistics. RESULTS: The greatest degree of reliability for a descriptor was found for mass orientation (k = 0.61) and the least concordance of fair was found for the mass margin (k = 0.32) and echo pattern (k = 0.36). Others descriptive terms: shape, lesion boundary and posterior features (k = 0.42, k = 0.55 and k = 0.53, respectively) and the final assessment (k = 0.51) demonstrated only moderate levels of agreement. A substantial degree of intraobserver agreement was found when classifying all morphologic features: shape, orientation, margin, lesion boundary, echo pattern and posterior feature (k = 0.73, k = 0.68, k = 0.64, 0.68, k = 0.65 and k = 0.64, respectively) and rendering final assessments (k = 0.65). CONCLUSION: Although BI-RADS-US was created to achieve a consensus among radiologists when describing breast abnormalities, our study shows substantial intraobserver agreement but only moderate interobserver agreement in the mass description and final assessment of breast abnormalities according to its use. A better agreement will ultimately require specialized education, as well as self-auditing practice tests.

Heterogeneity of Invasive Ductal Carcinoma: Proposal for a Hypothetical Classification

To investigate what heterogeneity exists in breast cancer, 228 consecutive patients with operable invasive duetal carcinoma (IDC), not otherwise specified, were categorized on the basis of the horizontal progression model of carcinogenesis. Using the reversed Black's nuclear grade (RBNG) in the IDC component and the association of ductal carcinoma in situ (DCIS), the patients were classified into pure IDC (IDC de novo or ab initio) as Group I, non-high grade (RBNG 1 and 2) IDC with DCIS as Group II, and high grade (RBNG 3) IDC with DCIS as Group III. The Groups classified in the present study appeared as a prognostic factor independent of known prognostic and predictive factors in multivariate test. Group I had the worst prognosis among the three groups and was the most non-responsive to tamoxifen. After performing stratifying analyses by group, it was found that metastasis-free survival was statistically associated with the status of hormone receptors estrogen receptor and progesterone receptor and tamoxifen therapy only in Group II. In addition, the status of c-erbB-2 expression had prognostic significance only within the Group III. Our results may be used to frame an alternative hypothetical model for breast cancer evolution and will lead us to reconsider the tailoring of the comprehensive therapeutic modality used at the present time.

Variação interobservador no diagnóstico histopatológico do carcinoma ductal in situ da mama / Interobserver variation of the histopathologic diagnosis of ductal carcinoma in situ of the breast

OBJETIVOS: fazer avaliação crítica do diagnóstico histopatológico do carcinoma ductal in situ (CDIS) da mama empregando a variação interobservador quanto ao diagnóstico, padrão arquitetural predominante, grau nuclear e grau histológico. MÉTODOS: oitenta e cinco casos com diagnóstico inicial de CDIS foram revisados por um mesmo patologista, especialista em patologia mamária, que selecionou 15 casos para análise interobservador. A análise foi realizada por cinco patologistas e um especialista internacional em patologia mamária, que receberam as mesmas lâminas e um protocolo para classificar as lesões em hiperplasia ductal atípica (HDA), CDIS e CDIS com microinvasão (CDIS-MIC). Caso o diagnóstico fosse de CDIS, os patologistas deveriam também classificá-lo quanto ao padrão arquitetural, grau nuclear e grau histológico. Os resultados foram analisados usando-se concordância percentual e o teste kappa. RESULTADOS: houve grande variação diagnóstica interobservador. Em um caso tivemos todos os diagnósticos, desde HDA, CDIS até CDIS-MIC. Usando o teste kappa para a comparação entre os diagnósticos dos cinco observadores e o especialista internacional obtivemos concordância interobservador mínima (<0,40). Quanto à classificação do CDIS em relação ao padrão arquitetural e ao grau histológico, os valores do teste kappa foram considerados ruins quanto à concordância interobservador. Os melhores resultados foram obtidos na análise da concordância quanto ao grau nuclear, com índices kappa de até 0,80, considerados como boa concordância. CONCLUSAO: os baixos índices de concordância interobservador no diagnóstico e classificação do CDIS da mama indicam a dificuldade na utilização dos critérios diagnósticos mais empregados na literatura na interpretação destas lesões e a necessidade de treinamento especifico dos patologistas não-especialistas no diagnóstico destas lesões

Evaluation of estrogen receptors in relation to activity of breast duct carcinoma

Breast cancer is the most common cause of death in middle aged women and affect a million women worldwide each year. The breast is the target organ for estrogen. This hormone controls several functions of the normal and abnormal mammary epithelium inducing cell proliferation. Most of the actions of estrogen are mediated via specific steroid receptors, and proliferate cells should contain estrogen receptors [ERs]. Several tumor markers have been mentioned for breast cancer like carcinoembryonic antigen [CEA], and cancer antigen [CAI5-3]. This study included 23 individuals participated in the study and were divided into 2 groups, group [1] [benign group which was considered the control group and group [2] [malignant group] which was subdivided into 3 groups according to the pathological grading. The expression of estrogen receptors [ER] was immunohistochemically investigated in 18 formaline-fixed paraffin embedded invasive breast carcinoma. 9 cases of 18 [50%] showed a positive nuclear immunoreactivity with both MoAbs against ER. In this study we found a distinct extremely significant and direct proportional relationship [p <0.01] between the histological grades [I, II, III] and ER nuclear immunoreavtivity. The majority of grade [III] tumors 4/5 [80%], were [ER] positive. In contrary grade [I] tumors and grade [II], 5/13 [3 8%] had low number of[ER] positive than the high grade [grade III]. In this study, the ER positive nuclear staining pattern was classified according to their intensity. The intensity of ER in different grades was, in grade [I] the weak intensity [+] was 1/1 [100%] while the moderate intensity [++] and strong [+++] were 0%. In grade [II], the weak intensity [+] was 1/4 [25%], the moderate was 3/4 [75%] and the strong was 0%. In grade [III], the weak intensity [+] was 0% while the moderate was [25%] and the strong record the maximum level 3/4 [75%.] The level of estrogen hormone in breast cancer patients as well as in control women. The mean level of estrogen hormone in cancer breast patients was extremely significant elevated than that in corresponding control [p=<0.0001[. The mean level of estrogen hormone was directly proportional with the histopathological grades. Serum CAI5.3was significantly increase than that in corresponding control. There was a direct proportional correlation between tumor grade and serum level of CAl 5.3 as a tumor marker for cancer breast. By comparison between different groups of patients with cancer breast we found that serum level of CAl 5.3 was significantly increased in grade II than grade I [p>0.05] and this correlation was extremely significant between grade III and both grade I and Grade II [p<0.01]. CEA was increased in cancer breast patient than that in corresponding control, this increase not reach the significance level in patients with grade I and grade II while in grade III this increase reach the significance level [p>0.01]. Among the different groups there was no any significant correlation between them in CEA level

Graduação nuclear do carcinoma invasivo de ductos mamários em punção aspirativa por agulha fina: estudo comparativo com grau histológico e avaliação da concordância intra e interobservador / Nuclear grading of the invasive ductual carcinoma of the breast in fine-needle aspiration biopsy: a comparative study with histological grading and evaluation of the intra- and inter-observer agreement

Realizou-se estudo retrospectivo de 90 casos de carcinoma invasivo de ductos mamários, diagnosticados por punção aspirativa por agulha fina (PAAF), com confirmação histológica, para avaliar a concordância citoistológica do grau nuclear e a reprodutibilidade intra e interobservador entre patologistas de um laboratório privado. Os preparados citológicos corados pela hematoxicilina-eosina foram examinados por dois patologistas, utilizando-se a graduação nuclear de Black modificada por Fisher (BM) e Black simplificada por Cajulis (BS). Os resultados foram controlados entre si e com a graduação de Bloom e Richardson na histologia. O índice de concordância com o grau histológico variou de 64,4% e 68,8% na classificação BM e de 86,6% a 88,8% na classificação BS. O sistema BM mostrou reprodutibilidade intra-observador de 68,8% e interobservador de 56,6% a 68,8%; enquanto o BS, de 93,3% e de 82,2% a 84,4%, respectivamente. Constatou-se que a graduação nuclear na PAAF utilizando-se o sistema de Black simplificado teve maior concordância com grau histológico e melhor reprodutibilidade intra e interobservador, quando comparada com o sistema Black modificado. Diante dos resultados demonstrados pela análise estatística (medida de concordância kappa), concluiu-se que grau nuclear é aplicável em material citológico e tem alta reprodutibilidade.

A retrospective study was performed on 90 cases of invasive breast ductal carcinoma, diagnosed by fine-needle aspiration biopsy (FNAB) and confirmed by histology, to evaluate the cyto-histological agreement of nuclear grading and to evaluate the intra- and inter-observer reproducibility between private laboratory's pathologists. Cytological smears stained with hematoxilin-eosin were graded by two independent pathologists, using Black's nuclear grading modified by Fisher (BM) and Black's simplified by Cajulis (BS). This was then compared with Bloom & Richardson's histological grade. The histological agreement rate was between 64.4% and 68.8% for BM classification and between 86.6% and 88.8% for BS. Grading using BM classification showed intra- and inter-observer reproducibility rates of 68.8% and from 56.6% to 68.8% respectively, while BS showed 93.3% and from 82.2% to 84.4% respectively. Nuclear grading in FNAB using Black's simplified system gave a higher level of agreement with the histological grade and better intra- and inter-observer reproducibility than Black's modified system. From statistical analysis (Kappa concordance level) we concluded that nuclear grade is applicable in cytological material and it shows good reproducibility.