ER, PR and HER2 discordance between 1ry and recurrent breast cancer

Presented By

Mohamed Mohamed Alhefny

Evaluation of Discordance Rate of HER2, ER, PR Receptors Status between

Primary Breast Cancer and Distant Metastasis or Locoregional

Recurrences

Faculty of MedicineAin Shams University

2014

Breast cancer is by far the most frequent cancer among women with incidence rates vary from 19.3 per 100,000 women in Eastern Africa to 89.7 per 100,000 women in Western Europe.

Breast cancer death rates have been decreasing in North America and several European countries over the past 25 years, largely as a result of early detection through mammography and improved treatment.

Review of Literature

Figure: (1) Breast cancer incidence mortality.


In the national cancer registry program of Egypt, breast cancer accounts for 40% of cancer cases in Aswan profile, 32.9% in Damitta profile and 26.8% in El-Minia profile. (Ibrahim et al., 2010).

Also constitutes 37% of all females cancers at national cancer institute (NCI) and 50% in private series. The median age is 46 years. (Ali Eldin , 2010).

In Ain shams university, average 3 years incidence from 2011-2013, breast cancer was by far the most frequent cancer, representing approximately 29% of all new cases. (In Ain Shams University, from 2011 -2013).


Hormonal receptors and HER2 in breast cancer

Estrogen receptor (ER) and progesterone receptor (PR), are therapeutically and prognostically important markers in the management of breast carcinoma.

About 65% to 75% of breast cancers express ER protein, and these tumors are associated with better prognosis, and about 65% of ER positive breast cancers are also progesterone receptor positive, and about 25% of breast cancers are ER negative and PR negative, about 10% of breast cancers are ER positive and PR negative, and about 5% of breast cancers are ER negative and PR positive.


ER status is important in predicting the response to adjuvant hormonal therapy.

PR is a surrogate marker of functional ER

because PR is an estrogen-regulated gene. Hence, simultaneous analysis of ER and PR

gives more information regarding likely hormonal response .

Many studies demonstrated a decrease in the ER and PR content as a tumor progresses.



Several studies have investigated expression of hormonal receptors of primary breast carcinomas and their metastases, mainly comparing ER and PR status of the primary tumor with regional nodal metastases. Some authors have lumped local recurrences and distant metastases together as one group.

Distant metastases, however, may not be biologically equivalent to local recurrences or regional axillary lymph node metastases, potentially behaving as clonal outgrowths with genetic modifications that may not be detectable in the primary tumors.

The discordance rate of ER between primary breast cancer and corresponding locoregional recurrences and distant metastases ranged from 12% to 30%, and in PR ranged from 18% to 40%.



HER-2 gene amplification and/or protein overexpression has been identified in approximately 25% of invasive breast cancers, unlike a variety of other epithelial malignancies, in breast cancer, HER-2 gene amplification is uniformly associated with HER-2 protein overexpression and the incidence of single copy overexpression is exceedingly rare.

HER-2 gene amplification in breast cancer has been associated with increased cell proliferation, cell motility, tumor invasiveness, progressive regional and distant metastases, accelerated angiogenesis, and reduced apoptosis.

Discordance rates of 8%–26% have been reported when compared HER2 of primary breast cancers and locoregional or systemic recurrences, but generally the discordance rate of HER2 is much less than hormonal receptors discordance.



Possible explanations for discordance in receptor status include: Pre-analytic and analytic variability (eg. Sampling errors, different techniques in processing and performing the tests). Intra-tumoral heterogeneity. Clonal selection.Variable ER-lineage differentiation of a putative disseminated breast cancer stem cell during the course of the disease.Selective effect of previous treatments (Adjuvant endocrine, chemotherapy and trastuzumab therapy).Switch in tumor biology (eg. dedifferentiation)



The introduction of selective molecular targeted therapy, specifically hormonal therapy and trastuzumab, has significantly altered the clinical behavior of breast carcinoma, several questions remain, regarding potential phenotypic drifts in ER, PR, and Her-2 expression between the primary and metastatic site.

The clinical implication of this instability is important, whereas loss of ER and HER2 generally means resistance to endocrine therapy and trastuzumab, respectively; thus, those patients would benefit from a change in therapy. However, in ER-positive patients, PR status has not been found to be predictive of tamoxifen response.



Equally, gain of ER and HER2 in the relapse setting would introduce additional choices of therapies, potentially leading to tumor response and prolonged survival in some patients.

A change in the tumor phenotype was associated with both significantly shorter post relapse survival (PRS) and OS, within the discordant group, a loss of a receptor expression rather than gain was associated with poor prognosis.

Patients who changed their tumor phenotype to triple negative (TN) by losing HR and/or HER2 expression experienced the shortest PRS and OS when compared with concordant cases.



This is a prospective clinical trial, was carried out in Clinical Oncology and Nuclear Medicine Department, Ain Shams University Hospitals during the period from June 2012 till June 2014.

This study included 62 eligible patients with metastatic breast cancer (MBC) or locoregional recurrent breast cancer.

This study was conducted to determine the HER2, ER and PR expression discordance between primary breast carcinoma and matched distant metastasis or locoregional recurrence.

Patients & Methods

Eligibility Criteria: Gender: females. Age: more than 18 years old.

Pathologically proved breast cancer with clinical, radiological or histopathological evidence of metastasis or locoregional recurrence.

Available primary tumor paraffin blocks and / or available pathological reports of the primary tumor including the immunohistochemical reports of estrogen receptors (ER), progesterone receptors (PR) and HER2.

Patients who are scheduled for anti-tumor treatment in the next 6 weeks.

With an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2.

Patients reliable for follow up.

Patients & Methods

Exclusion Criteria: Patients with medical conditions or cognitive

impairment that might impede a proper understanding of the written informed consent, according to medical criteria.

Patients developed contralateral breast lesion.

Patients diagnosed with a second malignancy, with the exception of cervical carcinoma in situ and non-melanoma skin carcinoma treated properly.

Patients not fit for any type of anti-tumor treatment or refusing further treatment.

Pregnant and lactating females.

Patients & Methods

STUDY DESIGNIn the first meeting with the patient: (Pre-biopsy assessment):Proper history.Assessment of performance status.Documentation of pathological data of the primary tumor.Documentation of hormonal status of the 1ry tumor.Documentation of the adjuvant treatment.Obtaining of written informed consent.The decision of the treating oncologist is documented before obtaining a biopsy from a metastatic lesion, to determine their treatment plan and then compared with the decision after biopsy results.

Patients & Methods

STUDY DESIGN (Cont..)

Biopsy procedure:

Eligible patients with clinical or radiological evidence of locoregional recurrence or metastasis will be biopsied from the most accessible and feasible site.

Biopsy and cytology techniques includes:Core biopsy:For superficial tumors palpation guided biopsy.For deep or internal tumors ultrasound guided or computed tomography guided biopsy.Excisional biopsy.Fine needle aspiration cytology (if the previous methods not feasible).

Patients & Methods

Patients & Methods


Tissue Processing: All resected specimens were either immediately fixed in

10 % buffered formalin or transported fresh to the pathology laboratory within 1–2h of removal from the patient during which specimens were kept cool (not to influence immunohisto-chemistry), while biopsies were immediately fixed.

Confirmation of malignancy and evaluation of hormonal receptors (estrogen and progesterone receptors) and HER2 expression were done for all available specimens and compared with corresponding results for the primary tumor using immunohistochemistry, if HER2 status is equivocal (HER2 score 2+) biopsies will be retested for HER2 oncogene by Fluorescence In Situ Hybridization (FISH), all primary and metastatic tissues were evaluated using the same standardized methodology.

ER and PR assay:

A positive result was defined as equal or more than 1% of tumor cell nuclei staining positively with any intensity.

Quantification systems for ER and PR includes:

1- Percentage of positive cell.

2- Intensity.

3- H score.

4- Allred Score: the most common used method for assay in this study.

Patients & Methods



Patients & Methods

Figure: (2) Allred scoring guidelines

HER2 assay:Assessment of IHC results of HER2 based on HercepTest scale (0, 1+, 2+, and 3+) using the specific immunohistochemical scoring criteria defined in the ASCO/CAP guidelines.

Patients & Methods


Figure: (3): ASCO/CAP guidelines for HER2 assay using IHC

IHC result of 2+ is considered equivocal and FISH is performed using the PathVysion HER-2 DNA Probe Kit.

Patients & Methods


Results of HER2 test by FISH (Single-probe) ASCO-CAP guidelines.

Results of HER2 test by FISH (Dual-probe) ASCO-CAP guidelines.

Figure: (4): ASCO/CAP guidelines for HER2 -FISH

Study endpoints Primary endpoint:

To determine the discordance rates of HER2, ER and PR status between primary breast cancer and their matched metastatic diseases or locoregional recurrences.

Secondary endpoints: Evaluate the disease free survival (DFS) of patients with and without

HER2, ER or PR discordance.

Evaluate HER2, ER and PR discordance rates compared to previously received systemic anti-tumor treatment.

Evaluate if there is any association between the stage of the primary breast cancer and the rate of discordance.

Evaluate whether the location of recurrence (loco-regional versus systemic) relates to the discordance rate.

Evaluate if there is any association between the grade of the primary breast cancer and the rate of discordance.

Evaluate if there is any association between the age and menopausal status of the patients and the rate of discordance.

Patients & Methods

Patients’ Characteristics

Results

Patients characteristics N. Percent (%)

Age

Mean 49.70

SD 9.900

Min. 29

Max. 70

Menopausal statusPremenopausal 26 41.9%

Postmenopausal 36 58.1%

Neoadjuvant therapyNo 58 93.5%

Yes 4 6.4%

Type of surgery

MRM (modified radical mastectomy)

44 71.0%

BCS (Breast conservative surgery) 18 29.0%

Pathology of primary disease Grade N. Percent (%)

IDC

Gr I 2 3.2%Gr II 45 72.6%Gr III 11 17.7%

ILC Gr II 2 3.2%Others Gr II 2 3.2%

Stage N. Percent (%)

T

1 5 8.1%2 31 50.0%3 19 30.6%4 7 11.3%

N

0 20 32.3%1 20 32.3%2 11 17.7%3 11 17.7%

Stage groupsI 2 3.2%II 27 43.5%III 33 53.2%

Table (1): Patients’ Characteristics

Results

Adjuvant therapy N. Percent )%(

Adjuvant anthracycline based CTHNo 12 19.4%

Yes 50 80.6%

Adjuvant trastuzumabNo 58 93.5%

Yes 4 6.5%

PORTNo 10 16.1%

Yes 52 83.9%

Adjuvant Hormonal treatmentNo 27 43.5%

Yes 35 56.5%

Recurrence N. Percent )%(

OverallLoco-regional 47 75.8%

Systemic 15 24.2%

Table (1): Patients’ Characteristics (cont…)

Discordance RatesER discordance:

There were 14 patients (22.6%) had discordance between the primary ER status and the ER status of the compared locoregional recurrence or distant metastasis.

In 11 patients (17.7%) ER changed from positive to negative, and in 3 patients (4.8%) ER changed from negative to positive.

There was statistically significant difference between the primary ER status and the ER status of the compared locoregional recurrence or distant metastasis (p=0.029).

Results

Results

Figure (5) : Showing ER discordance rate.

Results

PR discordance:

Twenty-one patients (33.9%) had discordance between the primary PR status and the PR status of the compared locoregional recurrences or distant metastasis.

In 16 patients (25.8%) PR changed from positive to negative, while in 5 patients (8.1%) PR changed from negative to positive.

There was statistically significant difference between the primary PR status and the PR status of the compared locoregional recurrences or distant metastasis (p=0.027).

Figure (6): Showing PR discordance rate.

Results

Results

HER discordance:

There were 7 patients (11.3%) had discordance between the primary HER2 status and the HER2 status of the compared locoregional recurrence or distant metastasis.

In 5 patients (8.1%) HER2 changed from positive to negative, while in 2 (3.2%) patients HER2 changed from negative to positive.

There was no statistically significant difference between the primary HER2 status and the HER2 status of the compared locoregional recurrences or distant metastasis (p=0.45).

Results

Figure (7): Showing HER2 discordance rate.

Overall discordance:

Overall discordance (change in any one of the three examined receptors ER or PR or HER2) was noted in 24 patients (38.7%), while in 38 patients (61.3%) the receptors (ER, PR and HER2) remained stable in the primary breast tumor and matched locoregional recurrences or distant metastasis.

Figure (8): Showing overall discordance rate.

Results

DFS and Receptors Discordance

In the 24 patients with receptors discordance the mean DFS was 33.8 months (SEM±4.2) whereas in patients without receptors discordance the mean DFS was 40.5 months (SEM±8.2).

There was no statistically significant difference between patients with receptors discordance and patients without receptors discordance as regard disease free survival (DFS) (p=0.4).

Results

Figure (9): Showing DFS in patients with and without overall discordance.

As regard overall discordance (discordance in any of the three receptors), among those patients with locoregional recurrences (n=47), 17 patients (36.2%) had discordance, and in 30 patients (63.8%) receptors remained unchanged.

Within the 15 patients with systemic recurrences, 7 patients (46.7%) had discordance, and in 8 patients (53.3%) receptors remained unchanged.

There was no statistically significant difference between patients with locoregional recurrences and systemic recurrences as regard overall discordance rate (p=0.46).

Locoreginal vs. Systemic Recurrences

Results

Results

Figure (10): Showing the relationship between the site of recurrence (locoregional vs. systemic) and overall receptors

discordance.

Locoreginal vs. Systemic Recurrences

ER Discordance

X2 P value Sig

No YesWas +ve &becam

e –ve

Was -ve &becam

e +ve

Adjuvant Hormonal treatment

NoN. 23 4 1 3

1.650 0.008 S∗∗Row % 85.2% 14.8% 3.7% 11.1%

YesN. 25 10 10 0

Row % 71.4% 28.6% 28.6% 0%

Table (2): Relationship between ER discordance and Adjuvant Hormonal treatment

∗ Chi square Test (X2)∗∗ S: Significant

Effect of adjuvant systemic treatment on receptors discordance.

Results

PR Discordance

X2

P valu

eSig.

No YesWas +ve &becam

e –ve

Was -ve &becam

e +ve

Adjuvant Hormonal treatment

No

N. 21 6 3 3

2.898 0.06 NS∗∗

Row % 77.8% 22.2% 11.1% 11.1%

Yes

N. 20 15 13 2

Row % 57.1% 42.9% 37.1% 5.7%


Table (3): Relationship between PR discordance and Adjuvant Hormonal treatment

∗ Chi square Test (X2) ∗∗N S: Non-Significant

Results

HER2 Discordance

X2 P value

SigNo Yes

Was +ve became

–ve

Was -ve became

+ve

Adjuvant Anthracycline -based

CTH

NoN. 12 0 0 0

1.894 0.32 NS∗∗

Row % 100.0% 0.0% 0.0% 0.0%

YesN. 43 7 5 2

Row % 86.0% 14.0% 8.1% 3.2%


Table (4): Relationship between HER2 discordance and adjuvant Anthracycline-based chemotherapy

∗ Chi square Test (X2)∗∗ NS: Non-Significant

Results

HER2 Discordance

X2 P value Sig.

No Yes

Adjuvant trastuzumab

NoN. 53 5

6.397 0.011 S∗∗Row % 91.4% 8.6%

YesN. 2 2

Row % 50.0% 50.0%

Table (5): Relationship between HER2 discordance and Adjuvant trastuzumab


∗ Chi square Test (X2) ∗∗ S: Significant

Results

Our study revealed a change in treatment decision according to re-biopsy and re-assessment of ER, PR and HER2 of the recurrent disease in 17.7% of the patients (n=11).

Impact on treatment decision

N. Percent (%)

Change in treatment decision

No 51 82.3

Yes 11 17.7

Table (6): Change in treatment decision

Results

There was no statistically significant difference between different stages of the primary breast cancer (stages I, II and III) and any of the receptors discordance and the overall discordance rates (p=0.3).

Also there was no statistically significant difference between different primary tumors grades and overall discordance rates (p=0.29).

There was no statistically significant difference between premenopausal and postmenopausal patients as regard overall discordance rates (p=0.16).

Primary tumor (1ry tumor stage and grade) and patient’s characteristics and receptors discordance

Results

Primary tumor characteristics (1ry tumor stage and grade) and receptors discordance

Figure (11): Showing the relationship between stage of 1ry tumors and overall receptors

discordance.

Results

In the current study, assessment of ER discordance between primary and recurrent breast cancer showed discordance rate of (22.6%) with statistically significant difference (p=0.02), ER changed from positive to negative in 11 patients (17.7%) and from negative to positive in 3 patients (4.8%).

This goes in accordance with the findings of Guarneri and colleagues (2008) and Liedtke and Colleagues (2009), they reported ER discordance rates of 22% and 18.4% respectively.

Also Lindstrom and Colleagues (2012), revealed a statistically significant difference between ER of primary and relapsed tumors (p<0.001).

The study by Amir and Colleagues (2012), reported a discordance rate of (16%) in ER status between primary and recurrent breast cancer, they showed that only 4 cases gained ER, and11 lost the ER expression.

Discussion

The current study revealed a discordance of PR in 21 cases of 62 patients evaluated (33.9%) with statistically significant difference between PR status of primary breast tumor and PR status of recurrence (p=0.02), PR changed from positive to negative in 16 patients (25.8%) and from negative to positive in 5 patients (8.1%).

This goes in accordance with the findings of Guarneri and Colleagues (2008), as they reported a discordance rate of 36% with statistically significant difference (p=0.028), among those patients with PR discordance 21 cases (28%) PR changed from positive to negative and 6 cases (8%) PR changed from negative to positive.

A study by Dieci and Colleagues (2013), evaluated 119 patients for receptor discordance and reported a discordance rate of 39% in PR, with PR loss is the main type of change.

Discussion

Our study revealed a discordance in HER2 in 7 patients, with discordance rate of 11.3%, with non significant difference (p=0.45), in 5 cases (8.1%) HER2 changed from positive to negative, and in 2 cases (3.2%) HER2 changed from negative to positive.

This goes with concordance with Guarneri and Colleagues (2008), Liedtke and Colleagues (2009), and Amir and Colleagues (2012), they reported a HER2 discordance rates of (16%), (13.6%) and (10%) respectively in their studies.

Also Dieci and Colleagues (2013), revealed a HER2 discordance rate of (11.8%).

The study by Pushpalatha and Colleagues (2010), showed a HER2 discordance rate of 7%, in (1%) HER2 changed from negative to positive, and in (6%) HER2 changed from positive to negative.

Discussion

The current study found an overall discordance in 24 patients (38.7%), while in 38 patients (61.3%) the receptors (ER, PR and HER2) remained stable.

Similar to our findings, Guarneri and Colleagues (2008) and Simmons and colleagues (2009), showed an overall discordance rate in any of the triple receptors status between primary tumor and paired metastasis of (36%) and (40%) respectively.

In the same range were the results obtained by Amir and Colleagues (2012) and Curtit and Colleagues (2013), as they found an overall discordance rate of 37.6% and 42% respectively.

Discussion

In the current study, there was no significant difference in the disease free survival (DFS) between patients with receptors discordance and patients without receptors discordance.

This goes with concordance with the studies by Macfarlane and Colleagues (2012) and Curtit and colleagues (2013), which revealed that receptors discordance did not significantly affect the median DFS or overall survival.

In our study the effect of adjuvant systemic therapy was only significant in patients who received adjuvant hormonal therapy in down-regulation of ER and in patients received adjuvant trastuzumab in down-regulation of HER2.

Lower and Colleagues (2005), revealed that 34% of the patients with ER discordance who received adjuvant hormonal treatment and was ER positive in primary tumor changed to negative in the recurrent tumor.

A study by Pectasides and Colleagues (2006), demonstrated a statistically significant correlation between adjuvant trastuzumab and HER2 loss (p=0.01) but also this observation was in limited number of patients (n=6).

Discussion

Our study yielded that the management plan of the patients changed according to the results of recurrent biopsy and the re-assessment of ER, PR and HER2 in 17.7%.

In the BRITS Study by Thompson and Colleagues (2010), evaluated the change in management according to the new biopsy results and the receptors discordance revealed that in 17.5% (n=24 out of 137) the recurrent biopsy changed the management decision.

This goes in the same range as the study by Simmons and Colleagues (2009)and Amir and Colleagues (2012), they reported a change in the oncologist’s decision based on the biopsy and biomarkers changes in 20% and 14% respectively.

Discussion

Patients with locoregional recurrent breast cancer or metastatic breast cancer should underwent biopsy from the most feasible site of recurrence whenever possible, and testing of ER, PR and HER2 on the recurrent biopsy is recommended as there is a significant difference in the hormonal receptors between primary and metastatic tumors and this has a direct impact on the management plan and the prognosis.

Management of patients with recurrent breast cancer (locoregional or systemic) should be personalized depending on the biological behavior and receptors status of both the primary and the recurrent tumors, not only the characteristics of the primary tumors.

Immunohistochemical analysis for ER, PR and HER2 should be standardized according to the CAP guidelines in order to limit the analytical errors and inter-individual variations, and for better reproducibility.

Further studies are needed to evaluate the effect of receptors discordance on prognosis and survival, specially the PFS and OS.

Recommendations

ER, PR and HER2 discordance between 1ry and recurrent breast cancer

Health & Medicine

primary breast cancer

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