here we go again: How inexact ER status testing is!!!

[Lani]

Not to worry you...these papers are useful. At the most recent bc conference I attended they even discussed changing the method by which ER is tested to make it more exact. How long that might take is another matter...Some of the fault may lie in the testing (and testers) but the tumor itself may have some areas with more and some with less ER

ABSTRACT: Quantitative analysis of estrogen receptor heterogeneity in breast cancer [Laboratory Investigation]
Immunohistochemical analyses (IHC) of biomarkers are extensively used for tumor characterization and as prognostic and predictive measures. The current standard of single slide analysis assumes that one 5 ?M section is representative of the entire tumor. We used our automated image analysis technology (AQUA) using a modified IHC technique with fluorophores to compare estrogen receptor (ER) expression in multiple blocks/slides from cases of primary breast cancer with the objective of quantifying tumor heterogeneity within sections and between blocks. To normalize our ER scores and allow slide-to-slide comparisons, 0.6 ?m histospots of representative breast cancer cases with known ER scores were assembled into a 'gold standard array' (GSA) and placed adjacently to each whole section. Overall, there was excellent correlation between AQUA scores and the pathologist's scores and reproducibility of GSA scores (mean linear regression R value 0.8903). Twenty-nine slides from 11 surgical cases were then analyzed totaling over 2000 AQUA images. Using standard binary assignments of AQUA (>10) and pathologist's (>10%) scores as being positive, there was fair concordancy between AQUA and pathologist scores (73%) and between slides from different blocks from the same cases (75%). However using continuous AQUA scores, agreement between AQUA and pathologist was far lower and between slides from different blocks from the same cases only 19%. Within individual slides there was also significant heterogeneity in a scattered pattern, most notably for slides with the highest AQUA scores. In sum, using a quantitative measure of ER expression, significant block-to-block heterogeneity was found in 81% of cases. These results most likely reflect both laboratory-based variability due to lack of standardization of immunohistochemistry and true biological heterogeneity. It is also likely to be dependent on the biomarker analyzed and suggests further studies should be carried out to determine how these findings may affect clinical decision-making processes.

[Soccermom]

Oh My Goodness Lani, I NEVER thought to question my ER status, nor the method that was used to test for it! I DID make MDAnderson repeat my Her neu test using FISH (IHC used initially).
You are amazing! Thank you for all you bring to our attention!
Marcia

[Lani]

In case you didn't catch it, within the last month I posted a study out of the UK showing that the use of methylene blue dye by the surgeon to identify the
sentinel node and/or the track of the localization needle for biopsy alters the result of the most common method of ER testing such that there appears to be less ER than there truly are. Utilize search and look up methylene blue.

Other more expensive dyes did not, but methylene blue was used overwhelmingly in the US for these purposes.

[Hopeful]

Lani,

Thanks for posting this report. I was reading an article last year on the possibility for some ER+ women with small cancers not to be routinely rx with chemo, and one of the doctors interviewed said part of the reluctance to come out with such a guideline had to do with the inexactitude, for want of a better word, of ER testing - that it vaired more from lab to lab than Her2 testing, and that it was the big problem no one talked about.

I have also read that there is a difference in the intensity of the ER staining, which provides additional info to the sheer number of the cells that stain for positive. Do you have any info on that?

Thanks,

Hopeful

[Lani]

J Natl Cancer Inst. 2006 Nov 1;98(21):1571-81. Links
Re-evaluating adjuvant breast cancer trials: assessing hormone receptor status by immunohistochemical versus extraction assays.

Regan MM, Viale G, Mastropasqua MG, Maiorano E, Golouh R, Carbone A, Brown B, Suurküla M, Langman G, Mazzucchelli L, Braye S, Grigolato P, Gelber RD, Castiglione-Gertsch M, Price KN, Coates AS, Goldhirsch A, Gusterson B; International Breast Cancer Study Group.
IBCSG Statistical Center, Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, 44 Binney St., Boston, MA 02115, USA. mregan@jimmy.harvard.edu
BACKGROUND: Tumor levels of steroid hormone receptors, a factor used to select adjuvant treatment for early-stage breast cancer, are currently determined with immunohistochemical assays. These assays have a discordance of 10%-30% with previously used extraction assays. We assessed the concordance and predictive value of hormone receptor status as determined by immunohistochemical and extraction assays on specimens from International Breast Cancer Study Group Trials VIII and IX. These trials predominantly used extraction assays and compared adjuvant chemoendocrine therapy with endocrine therapy alone among pre- and postmenopausal patients with lymph node-negative breast cancer. Trial conclusions were that combination therapy provided a benefit to pre- and postmenopausal patients with estrogen receptor (ER)-negative tumors but not to ER-positive postmenopausal patients. ER-positive premenopausal patients required further study. METHODS: Tumor specimens from 571 premenopausal and 976 postmenopausal patients on which extraction assays had determined ER and progesterone receptor (PgR) levels before randomization from October 1, 1988, through October 1, 1999, were re-evaluated with an immunohistochemical assay in a central pathology laboratory. The endpoint was disease-free survival. Hazard ratios of recurrence or death for treatment comparisons were estimated with Cox proportional hazards regression models, and discriminatory ability was evaluated with the c index. All statistical tests were two-sided. RESULTS: Concordance of hormone receptor status determined by both assays ranged from 74% (kappa = 0.48) for PgR among postmenopausal patients to 88% (kappa = 0.66) for ER in postmenopausal patients. Hazard ratio estimates were similar for the association between disease-free survival and ER status (among all patients) or PgR status (among postmenopausal patients) as determined by the two methods. However, among premenopausal patients treated with endocrine therapy alone, the discriminatory ability of PgR status as determined by immunohistochemical assay was statistically significantly better (c index = 0.60 versus 0.51; P = .003) than that determined by extraction assay, and so immunohistochemically determined PgR status could predict disease-free survival. CONCLUSIONS: Trial conclusions in which ER status (for all patients) or PgR status (for postmenopausal patients) was determined by immunohistochemical assay supported those determined by extraction assays. However, among premenopausal patients, trial conclusions drawn from PgR status differed--immunohistochemically determined PgR status could predict response to endocrine therapy, unlike that determined by the extraction assay.
PMID: 17077359 [PubMed - indexed for MEDLINE]

[Lani]

: Am J Clin Pathol. 2007 Mar;127(3):356-65. Links
Comparison of evaluations for hormone receptors in breast carcinoma using two manual and three automated immunohistochemical assays.

Arihiro K, Umemura S, Kurosumi M, Moriya T, Oyama T, Yamashita H, Umekita Y, Komoike Y, Shimizu C, Fukushima H, Kajiwara H, Akiyama F.
Department of Anatomical Pathology, Hiroshima University Hospital, Hiroshima, Japan.
The aims of this study were to compare the quality of immunohistochemical assays of estrogen receptor (ER) and progesterone receptor (PR) and to compare the intermethod variability of assays from different manufacturers. immunohistochemical staining was entrusted to the following laboratories in Japan: Kyowa Medex, dealing with the products of BioGenex (Mishima, Shizuoka), DAKO Japan (Kyoto) and Ventana Japan (Yokohama). All slides were semiquantitatively evaluated according to the Allred score. Intermethod variability showed fair to moderate multirater kappa values for ER and PR (for total score, ER, kappa = 0.34; PR, kappa = 0.45). Another scoring system was also applied in which, irrespective of the intensity of nuclear staining, the proportion of cells stained in each specimen was recorded as 0; less than 1%; 1% or more and less than 10%; or 10% or more. Intermethod variability showed substantial multirater kappa values for ER and PR (according to percentage of positive cells, ER, kappa = 0.67; PR, kappa = 0.72). Concerning intermethod consistency, the scoring system based on the percentage of positive cells was advantageous over other scoring systems.
PMID: 17276950 [PubMed - indexed for MEDLINE]


Related Links
Quality assurance for detection of estrogen and progesterone receptors by immunohistochemistry in Austrian pathology laboratories. [Virchows Arch. 2002]
The effects of fixation, processing and evaluation criteria on immunohistochemical detection of hormone receptors in breast cancer. [Breast Cancer. 2007]
Interobserver reproducibility of immunocytochemical estrogen- and progesterone receptor status assessment in breast cancer. [Anticancer Res. 1996]
Immunohistochemical demonstration of oestrogen and progesterone receptors: correlation of standards achieved on in house tumours with that achieved on external quality assessment material in over 150 laboratories from 26 countries. [J Clin Pathol. 2000]
Simultaneous immunohistochemical and biochemical hormone receptor assessment in breast cancer provides complementary prognostic information. [Anticancer Res. 1997]
See all Related Articles...

[Soccermom]

Lani...I must have missed that one! Which may be a good thing (for me) as I tend to get soooo worked up over things I cannot change.
Right now I am preparing to do battle with my Insurer so am preparing my plan of attack...
Michael Moore "LOOK OUT"!
Thanks again Lani!
Marcia

Thank you again!
Marcia

[TSund]

1) hmm...is the dye used on the intial needle biopsy as well as the sentinel node biopsy? (Ruth is getting "pre-surgery" chemo)

It has occured to me that in highly hormonal positive that the chemo may just be shutting down the ER via chemopause and this is the main way it works. HOWEVER I don't think that is true in Ruth's case as her dramatic response was very evident in 1st exam before 2nd treatment, and I've read that usually women have one more menstrual cycle before chemopause) Tho it's been 5 weeks and she's not had another cycle.

Lani, I was referring in #2 aboce to what I had read in reference to Herceptin working better WITH chemo than without, I believe regardless of ER status. So...this perhaps leads to the idea that all HER2+ should have chemo with Herceptin since we really need the Herceptin and you wnat it to work in the best possbile way? Or....it could translate into HER2+ tumors needing or responding to the chemo for some reason inherent in Her2+?

This has confused me, because I've read that herceptin works better with an intact immune system. So..since chemo generally can hurt the immune system, why does Herceptin work better with chemo???

THANKS~

Terri

THANK-yoU!

[Hopeful]

Terri,

The benefit of using Herceptin in an uncompromised immune system is thought to be via "Natural Killer" (NK) cells. These cells are noticeably reduced following most chemo. I did read an abstract: http://www.ncbi.nlm.nih.gov/sites/en...&dopt=Abstract Titled "Paclitaxel probably enhances cytotoxicity of natural killer cells against breast carcinoma cells by increasing perforin production," which may explain the positive results seen when combining paclitaxel with Herceptin.

Hope this helps,

Hopeful

[StephN]

I know of two cases among my friends here who have had new mets change from hormone positive to negative. Therefore stopping the AI they had been on for years. Both are HER2 positive and disease was progressing.

In one case it was new nodes in the neck and another case was bone. Each had biopsies to see why the old treatments were no longer working.

Also heard discussion at San Antonio that new mets can change hormone status, but don't recall about ER/PR neg can become positive for certain.
(You would think I would have remembered that one since I am hormone neg!) Maybe the talk did not cover that case.

[Lani]

Probably not all ER+her2+ breast cancers are alike--perhaps some have topoIIa amplified, some not, and many other differences. When they are all lumped together the average of them do better with herceptin and chemo than with chemo alone and when ER+ tumors (both her2+--about 10% of them--and her2negative tumors, the other 90% of them) are considered as a whole on AVERAGE they hardly respond to chemo. This is probably because subsets are not identified and the results are skewed.

Perhaps there are a group of her2+ER+ tumors that would do fine with herceptin and fulvestrant (more likely than with herceptin and an AI, according to Dr. Slamon) without chemo, but all we can say now, is that when all her2+ tumors ER+ or not were lumped together in the HERA, NO American combined, TCH (BCRG009) and Fin Her trials that upon analysis of all lumped together the % improvement in recurrence and survival did not differ between those who were ER+ vs ER- ON AVERAGE.

Noone is an average. Someday, hopefully, each tumor will be evaluated individually and treated differently.

To more fully respond to your question--It seems a subgroup of her2+ tumors respond particularly well to anthracyclines (perhaps the TOPO IIa amplified group) and another group respond particularly well to herceptin and taxanes (perhaps the cMyc group and perhaps all subgroups, but we don't know for sure yet). They have not yet dissected this out with respect to ER+ vs ER- from the talks I have heard/papers I have read.

And no, if only a needle biopsy and not an open or excisional biopsy or node biopsy were done, methylene blue would not have been used, from what I understand.

[TSund]

Lani,

You are about 1000% ahead of me as far as being well read up, but from what I understand about TOPO is that the latest info about Her2+ and TOPO flies in the face of what was thought previously. When Her2+ and Herceptin enters the equation, all of a sudden the anthrcycline is not necessary in chemo to achieve similar results (i.e the latest stats on TCH - San Antonio). The TOPO positive people do better in general, and that is true in HER2+ whether they do the AC+TH or TCH. I was given this answer when I asked our onc if the fact that Ruth was responding well to the TCH meant that she was TOPO negative as the other onc (not a bc specialist) had given us the hard core insistence that Ruth must have an anthracycline in case she was TOPO positive. I think I read something early on by Dr. Pegram (sp?) that indicates something similar.

[TSund]

Steph, were your friends that were progressing still on Herceptin?

And, do you know what percentage hormonally positve they were?

Thanks,

Terri