Clinical utility of the IHC4+C score in oestrogen receptor-positive early breast cancer: a prospective decision impact study.

BACKGROUND: Most oestrogen receptor (ER)-positive early breast cancer diagnosed today is highly curable with multimodality treatment. Systemic adjuvant treatments including endocrine therapy and chemotherapy have made a significant contribution to the increasing cure rates over the past three decades. However not all women will require chemotherapy. The IHC4+C score is a prognostic tool that integrates four immunohistochemical measures with clinicopathological features to estimate the residual risk of distant recurrence at 10 years in post-menopausal women with ER-positive breast cancer who have received 5 years of endocrine therapy. Retrospective studies indicate that the test can identify a set of women that are at such low risk of recurrence that chemotherapy can be of little benefit. METHODS: In this study, 124 patients were prospectively selected from the multidisciplinary team meeting between January 2013 and April 2014 for IHC4+C testing. Adjuvant systemic treatment recommendations by clinicians were recorded without and with the availability of the score in addition to the patient's decision. RESULTS: There was concordance in the MDT's recommendation without and with the availability of the score in 73% of cases. Clinicians recommended chemotherapy or at least its discussion to 74 (59%) patients, which fell to 32 (34%) patients after the IHC4+C score was made available, sparing one in four tested patients a chemotherapy recommendation, along with its toxicity and expense. CONCLUSION: This decision impact study shows that when used by clinicians in the multidisciplinary team meeting for adjuvant decision-making, a significant proportion of patients are spared chemotherapy recommendations.

HER2 staining intensity in HER2-positive disease: relationship with FISH amplification and clinical outcome in the HERA trial of adjuvant trastuzumab.

BACKGROUND: Trastuzumab treatment improves survival of HER2-positive primary breast cancer. HER2 staining intensity varies widely in HER2-positive tumours. PATIENTS AND METHODS: We investigated whether differences in immunohistochemical (IHC) staining intensity for HER2 in HER2-positive tumors (IHC 3+ or FISH ratio ≥2.0) was associated with prognosis or benefit from trastuzumab treatment in patients randomized to 1 year or no trastuzumab in the HERceptin Adjuvant (HERA) trial. Median follow-up was 2 years. The nested case-control analysis, included 425 patients (cases) with a disease-free survival (DFS) event and two matched controls (no DFS event) per case. Tissue sections stained for HER2 were assessed for HER2 staining intensity by image analysis. RESULTS: HER2 staining intensity varied widely and correlated with HER2 gene copy number (Spearman, r = 0.498, P < 0.001) or less closely with HER2/CEP17 FISH ratio (r = 0.396, P < 0.001). We found no significant difference in DFS in the observation arm according to staining intensity (odds ratio [OR] change per 10 unit change in intensity: 1.015, 95% confidence interval [CI] 0.930-1.108) and no impact of staining intensity on benefit derived from 1-year trastuzumab (OR: 1.017, 95% CI 0.925-1.120). CONCLUSIONS: Variability in HER2 staining in HER2-positive tumours has no role in clinical management with adjuvant trastuzumab. HERA TRIAL NO: NCT00045032.

Assessment of the contribution of the IHC4+C score to decision making in clinical practice in early breast cancer.

BACKGROUND: The immunohistochemical (IHC) 4+C score is a cost-effective prognostic tool that uses clinicopathologic factors and four standard IHC assays: oestrogen receptor (ER), PR, HER2 and Ki67. We assessed its utility in personalising breast cancer treatment in a clinical practice setting, through comparison with Adjuvant! Online (AoL) and the Nottingham Prognostic Index (NPI). METHODS: We prospectively gathered clinicopathologic data for postmenopausal patients with hormone receptor-positive, HER2-negative, N0-3 resected early breast cancer treated consecutively at our institution. We retrospectively calculated and compared prognostic scores. The primary endpoint was the proportion of patients reclassified from AoL-defined intermediate-risk by application of the IHC4+C score. RESULTS: The median age of the 101 patients included in the analysis was 63. In all, 15 of the 26 patients classified as intermediate-risk by AoL were reallocated to a low-risk group by application of the IHC4+C score and no patient was reclassified as high-risk group. Of the 59 patients classified as intermediate-risk group by the NPI, 24 were reallocated to a low-risk group and 13 to a high-risk group. CONCLUSION: IHC4+C reclassifies more than half of the patients stratified as being in intermediate-risk group by the AoL and NPI. The use of IHC4+C may substantially improve decision-making on adjuvant chemotherapy.

Relationship between estrogen receptor, progesterone receptor, HER-2 and Ki67 expression and efficacy of aromatase inhibitors in advanced breast cancer.

BACKGROUND: Surprisingly few data are published on the relevance of even commonly used biomarkers of response to aromatase inhibitors (AIs) in advanced breast cancer. Here, we aim to determine the effectiveness of AIs in that setting according to quantitative levels of estrogen receptor (ER), progesterone receptor (PgR) and Ki67 or human epithelial growth factor receptor-2 (HER-2) status. PATIENTS AND METHODS: ER, PgR, HER-2 and Ki67 protein expressions were centrally assessed in 177 archival formalin-fixed paraffin-embedded primary or locally recurrent breast tumours from women who subsequently received AI treatment of advanced disease. RESULTS: Among ER-positive patients (n = 146), higher PgR, but not ER, levels were associated with increased time to AI treatment failure (TTF). Higher Ki67 staining was associated with decreased TTF. ER-positive/HER-2-positive patients showed a non-significant trend for decreased TTF compared with ER-positive/HER-2-negative patients. PgR level, but not Ki67, remained a significant predictor of TTF in multivariate analysis of ER-positive patients. CONCLUSIONS: Higher PgR and Ki67 levels are significantly associated with increased and decreased TTF, respectively, in ER-positive patients receiving AI treatment of advanced disease. The higher proliferation seen in PgR-negative tumours does not explain the poorer clinical responsiveness of this subgroup.

Detection of circulating epithelial cells in the blood of patients with breast cancer: comparison of three techniques.

This study compares the sensitivities and specificities of three techniques for the detection of circulating epithelial cells in the blood of patients with breast cancer. The number of circulating epithelial cells present in the blood of 40 patients with metastatic breast cancer and 20 healthy volunteers was determined by: immunomagnetic separation (IMS) and laser scanning cytometry (LSC), cell filtration and LSC and a multimarker real-time RT-PCR assay. Numbers of cytokeratin-positive cells identified and expression of three PCR markers were significantly higher in the blood of patients with breast cancer than in healthy volunteers. Using the upper 95% confidence interval of cells detected in controls to determine positive patient samples: 30% of patients with metastatic breast cancer were positive following cell filtration, 48% following IMS, and 60, 45 and 35% using real-time RT-PCR for cytokeratin 19, mammaglobin and prolactin-inducible peptide. Samples were significantly more likely to be positive for at least one PCR marker than by cell filtration (83 vs 30%, P<0.001) or IMS (83 vs 48%, P<0.001). The use of a multimarker real-time RT-PCR assay was therefore found to be the most sensitive technique for the detection of circulating epithelial cells in the blood of patients with breast cancer.

Measurement of markers for breast cancer in a model system using laser scanning cytometry.

BACKGROUND: A variety of markers, including Ki67, estrogen receptors (ER), and progesterone receptors (PgR), are frequently measured in fine needle aspirates (FNA) from human breast carcinomas. We used a human breast carcinoma cell line, MCF7, as a model system to investigate the use of laser scanning cytometry (LSC) for the measurement of these markers. Additionally, we measured the number of apoptotic cells. METHODS: Cells were treated with drugs to vary the expression of markers and the number of apoptotic cells. They were then fixed on microscope slides. For LSC, the cells were stained for the different markers with fluorescein using immunofluorescence and for apoptotic cells using the TUNEL assay. The nuclei were counterstained with propidium iodide. A parallel set of slides was stained using horseradish peroxidase and diaminobenzidine and scored manually by conventional light microscopy. RESULTS: The results from the LSC closely paralleled those obtained by manual scoring of immunohistochemical stains. CONCLUSIONS: It should be possible to use LSC for the routine measurement of nuclear markers in FNAs from human breast carcinomas.

LHRH - modulator of progesterone and estradiol secretion by theca and granulosa cells on porcine follicle in mono- and co-culture.

Progesterone (P4) and estradiol (E2) secretion by granulosa and theca cells cultured alone or in co-culture under the influence of LHRH was studied. Follicular cells were separated from the follicles of different size: small (1-3 mm), middle (4-6 mm) and large (7-10 mm). The cells were cultured in medium M199 containing 100 ng LH/ml for 30 h. LHRH in a dose of 10[-8] M was added to LH treated cultures after 24 h in culture. Then the cultures were incubated with this hormone during subsequent 6 h. LHRH significantly increased LH-stimulated E2 secretion by granulosa cells (GC) harvested from small and middle follicles, but not from large ones. LHRH had no effect on P4 secretion by granulosa cells alone from small and middle follicles, but it significantly decreased P4 secretion in cultures of granulosa cells harvested from large follicles. In cultures of theca layers (T) alone, decreased secretion of E2 was observed from small follicles only. LHRH had no effect on P4 secretion by theca cell from large follicles cultured alone. However, it markedly increased P4 secretion by T cells from middle follicles and decreased that by theca cells from small follicles. In co-culture of granulosa and theca cells resembling an in vivo follicle, the addition of LHRH to LH stimulated cells harvested from small and middle follicles caused an increase of E2 and decrease of P4 secretion. On the other hand, in co-cultures of cells from large preovulatory follicles, both E2 and P4 secretion was suppressed. It may be concluded that the diverse effects of LHRH (either inhibitory or stimulatory) depend on the degree of follicular maturation.

Argyrophilic nucleolar organizer regions, bromodeoxyuridine labelling index and DNA ploidy in squamous cell carcinoma of the uterine cervix.

There is increasing evidence that rapidly proliferating tumours, i.e. those with a high bromodeoxyuridine labelling index (BrdUrdLI), could benefit from an accelerated course of radiotherapy. Also, DNA ploidy may be a prognostic factor in term of patients survival. Thus, measurements of cell kinetics and DNA ploidy might become part of routine characterization of tumours before treatment. It is supposed, that a simple and cheap argyrophilic nucleolar organizer regions (AgNOR) test reflects the proliferative status of the tumour and correlates with BrdUrdLI. The BrdUrdLI, AgNOR test and DNA ploidy were assessed in 49 squamous cell carcinoma (SCC) of the cervix (stage II B-III B) and 5 normal epithelium. The number of NORs per cell nucleus, the mean AgNOR particle area and the total AgNOR area per cell were evaluated. Significant differences in the proliferative rate were found within the examined groups of tumours assessed by the BrdUrdLI and AgNOR test. The mean BrdUrdLI values were significantly lower in normal than in carcinomatous cells, while for AgNOR values this was true for stage III B only. The mean number of AgNORs and total AgNOR area per cell were not significantly higher at stage III B than at stage II B, respectively. A high DNA aneuploidy was found in the examined tumours: 78% in stage II B and 77% in stage III B of disease. The results of proliferative markers were not significantly different in diploid than in aneuploid tumours. A significant correlation (p < 0.0001) was found between the mean AgNOR values and BrdUrdLI, however the correlation coefficient was poor (r = 0.50). This was due to different fragments of the same tumours used in these tests. Therefore these techniques might be used as independent methods reflecting the proliferative rate of the tumour.

Micronucleus assay in three transplantable mouse tumors.

The cytokinesis-block micronucleus (MN) assay was performed in three mouse tumors: two sarcomas (SaL, MCA) and Lewis lung carcinoma (LLC). To determine the optimal culture durations and cytochalasin B (cyt-B) concentrations to yield the highest proportion of binucleate cells (BC) for each tumor, the influence of the cyt-B concentration (1, 2 and 3 micrograms/ml) and culture duration (24-96) were studied. The amount of BC and the MN frequency was investigated for the different radiation doses (0-4 Gy). Dose response curves were constructed using the optimal culture duration and cyt-B concentration for each tumor. This was 24 h of incubation for MCA and 48 h for SaL and LLC and 2 micrograms/ml of cyt-B. The tumors examined differ in the mean number of spontaneously (0 Gy) occurring MN in binucleate cells. These were 0.008, 0.022 and 0.044 for MCA, SaL and LLC, respectively. The MN frequency increased with radiation dose. LLC was found to be the most radiosensitive, while MCA proved to be the least radiosensitive tumor. The average number of MN/BC at 2 Gy of irradiation (after subtraction of the value at 0 Gy) ranged from 0.05 to 0.36. The highest mean value -0.36 was shown in LLC, the middle-0.20 in SaL, and the lowest-0.05 in MCA tumor. After higher doses of irradiation numerous BC with two and more MN were found in LLC tumor, while they were not frequently observed in MCA tumor. We did not observe an increase in the MN frequency with culture duration or proliferation rate of the tumor cells. MCA has the shortest potential doubling time (Tpot) and had the lowest MN frequency from three examined tumors. The MN assay has promise to be a rapid predictive assay of radiosensitivity.