Confronto Interistituzionale in
Patologia Mammaria:
determinazione immunofenotipica di
ER/PR
Licia Laurino and Angelo P. Dei Tos
Dipartimenti di Patologia ed Oncologia
Treviso
Breast Cancer Diagnosis
• Necessary
• Difficult
• Insufficient for planning the
adjuvant treatment
St. Gallen Conference
• Absolute importance of timely,
accurate and reliable histopathologic
assessment
• Target identification and quantitation
• Enhanced partnership between
clinician and pathologists 
substantially improved outcomes.
Treatment Options
• Endocrine therapy
– Any detectable ER
• Anti HER2 therapy
– HER2 + (ASCO/CAP)
• Chemotherapy
Gene Epression Signatures
“…after a long debate, the Panel
supported the use of a validated
multigene-profiling assay, as an
adjunct to high quality phenotyping of
breast cancer in cases in which the
indication for adj chemo remained
uncertain”
Currently accepted prognostic/predictive
parameters
• Patient
characteristics
• Disease
characteristics
• Biomarkers
Age
(Race)
Tumor size
Tumor type
Axillary status
Tumor grade
Peritum. vascular invasion
Receptor status
HER2/neu expression
Ki-67 labeling index
The histopathologic report
• Invasive ductal ca,
NOS, G2, negative
margins, with 2
lymph node mets in
post-meno patient.
• ER: 90%; PgR 90%,
HER2 negative,
Ki67: 12%
• Endocrine-responsive
tumor with an
intermediate risk.
Adjuvant Tamoxifen for
2 yrs, followed by AI
for additional 3 yrs.
Then wait for the
results of current trials
of extended endocrine
treatment
The histopathologic report
• Invasive ductal ca,
NOS, G2, negative
margins, with 2
lymph node mets in
post-meno patient.
• ER: 90%; PgR 90%,
HER2 negative,
Ki67: 12%
• Endocrine-responsive
tumor with an
intermediate risk.
Adjuvant Tamoxifen for
2 yrs, followed by AI
for additional 3 yrs.
Then wait for the
results of current trials
of extended endocrine
treatment
Increasing Roles for Pathologist
•
Taxane most effective on endocrine Non or
INCOMPLETELY responsive tumors
–
 Optimal ER/PgR/HER2 assessment
•
Microtubule binding protein TAU predicts response to
Paclitaxel
•
Topoisomerase II alpha amplification and protein
overxpression predict response to anthracyclins (?)
•
Basal –like tumors (often associated with BRCA1) more
responsive to DNA damaging agents (platinum)
External quality controls for ER
• UK-NEQAS
(round #53)
– Score >12/20
– Score 10-12
– Score <10/20
49%
27%
24%
(#54)
69%
16%
15%
• German Q.A.:
– False-negative rate
= 11-24%
(Am J Surg Pathol 2002)
J Nat Cancer Inst 2008, 100:836.
CQ Veneto 09
• Inviate sezioni di mammella normale,
carcinoma papillare, (+vo) carcinoma
adenoidocistico (-vo), carcinoma
lobulare pleomorfo (debolmente +vo)
• 14 centri
Nor
ER
Nor
PR
Pos
ER
Pos
PR
Neg
ER
TV
OK
OK
100%
100%
0
A
OK
-
100%
disomog
100%
++
C
OK
OK
100%
disomog
D
Deb
Deb
E
Deb
F
G
Neg
PR
Deb
ER
Deb
PR
Metodica
0
2%
2%
SP1 / 636
Polimero
DAKO
0
Deb
pos
?
2%
deb
100%
deb ?
SP1/Ab8
ultravision
100%
0
0
3040%
?
0
?
Vector
Polimero
DAKO
50%
disomog
100%
0
Contr.
Ins.
0
0
Contr
. Ins.
0
Contr
. Ins.
SP1/Ab8
Bond-max
-
90%
disomog
100%
0
0
<5%
0
6F11/1A6
Bond-max
OK
OK
100%
100%
disomog
0
0
2%
0
Contr
. Ins.
SP1/ 1E2
Ventana
-
-
100%
90%
debole
0
0
2%
0
SP1/ 1E2
Ventana
Nor
ER
Nor
PR
Pos
ER
Pos
PR
Neg
ER
T
V
OK
OK
100%
100%
0
H
OK
OK
100%
100%
disomog
0
I
Deb
OK
100%
disomog
100%
Deb
ER
Deb
PR
0
2%
2%
SP1 / 636
Polimero
DAKO
0
2%
0
SP1 /1E2
Ventana
0
Contr
. Ins.
0
Contr
. Ins.
SP1 / 636
Polimero
L
OK
np
100%
disomog
100%
disomog
0
0
2%
0
Contr
. Ins.
6F11 / 636
Bondmax
N
Deb
OK
100%
100%
0
0
2%
0
Contr
. Ins.
SP1/1E2
?
O
OK
OK
100%
100%
0
0
2%
0
Contr
. Ins.
P
OK
OK
100%
np
2%
0
2%
0
Contr
. Ins.
?
?
R
Deb
Deb
60%
disomog
60%
disomog
0
0
0
Contr
. Ins.
0
Contr
. Ins.
?
?
S
OK
OK
100%
100%
0
0
2%
0
Contr
. Ins.
?
BondMax
0
Neg
PR
0
Metodica
SP1/1E2
Ventana
Nor
ER
Nor
PR
Pos
ER
Pos
PR
Neg
ER
TV
OK
OK
100%
100%
0
A
OK
-
100%
disomog
100%
++
C
OK
OK
100%
disomog
D
Deb
Deb
E
Deb
F
G
Neg
PR
Deb
ER
Deb
PR
Metodica
0
2%
2%
SP1 / 636
Polimero
DAKO
0
Deb
pos
?
2%
deb
100%
deb ?
SP1/Ab8
ultravision
100%
0
0
3040%
?
0
?
Vector
Polimero
DAKO
50%
disomog
100%
0
Contr.
Ins.
0
0
Contr
. Ins.
0
Contr
. Ins.
SP1/Ab8
Bond-max
-
90%
disomog
100%
0
0
<5%
0
6F11/1A6
Bond-max
OK
OK
100%
100%
disomog
0
0
2%
0
Contr
. Ins.
SP1/ 1E2
Ventana
-
-
100%
90%
debole
0
0
2%
0
SP1/ 1E2
Ventana
Nor
ER
Nor
PR
Pos
ER
Pos
PR
Neg
ER
T
V
OK
OK
100%
100%
0
H
OK
OK
100%
100%
disomog
0
I
Deb
OK
100%
disomog
100%
Deb
ER
Deb
PR
0
2%
2%
SP1 / 636
Polimero
DAKO
0
2%
0
SP1 /1E2
Ventana
0
Contr
. Ins.
0
Contr
. Ins.
SP1 / 636
Polimero
L
OK
np
100%
disomog
100%
disomog
0
0
2%
0
Contr
. Ins.
6F11 / 636
Bondmax
N
Deb
OK
100%
100%
0
0
2%
0
Contr
. Ins.
SP1/1E2
?
O
OK
OK
100%
100%
0
0
2%
0
Contr
. Ins.
P
OK
OK
100%
np
2%
0
2%
0
Contr
. Ins.
?
?
R
Deb
Deb
60%
disomog
60%
disomog
0
0
0
Contr
. Ins.
0
Contr
. Ins.
?
?
S
OK
OK
100%
100%
0
0
2%
0
Contr
. Ins.
?
BondMax
0
Neg
PR
0
Metodica
SP1/1E2
Ventana
Nor
ER
Nor
PR
Pos
ER
Pos
PR
Neg
ER
TV
OK
OK
100%
100%
0
A
OK
-
100%
disomog
100%
++
C
OK
OK
100%
disomog
D
Deb
Deb
E
Deb
F
G
Neg
PR
Deb
ER
Deb
PR
Metodica
0
2%
2%
SP1 / 636
Polimero
DAKO
0
Deb
pos
?
2%
deb
100%
deb ?
SP1/Ab8
ultravision
100%
0
0
3040%
?
0
?
Vector
Polimero
DAKO
50%
disomog
100%
0
Contr.
Ins.
0
0
Contr
. Ins.
0
Contr
. Ins.
SP1/Ab8
Bond-max
-
90%
disomog
100%
0
0
<5%
0
6F11/1A6
Bond-max
OK
OK
100%
100%
disomog
0
0
2%
0
Contr
. Ins.
SP1/ 1E2
Ventana
-
-
100%
90%
debole
0
0
2%
0
SP1/ 1E2
Ventana
Nor
ER
Nor
PR
Pos
ER
Pos
PR
Neg
ER
T
V
OK
OK
100%
100%
0
H
OK
OK
100%
100%
disomog
0
I
Deb
OK
100%
disomog
100%
Deb
ER
Deb
PR
0
2%
2%
SP1 / 636
Polimero
DAKO
0
2%
0
SP1 /1E2
Ventana
0
Contr
. Ins.
0
Contr
. Ins.
SP1 / 636
Polimero
L
OK
np
100%
disomog
100%
disomog
0
0
2%
0
Contr
. Ins.
6F11 / 636
Bondmax
N
Deb
OK
100%
100%
0
0
2%
0
Contr
. Ins.
SP1/1E2
?
O
OK
OK
100%
100%
0
0
2%
0
Contr
. Ins.
P
OK
OK
100%
np
2%
0
2%
0
Contr
. Ins.
?
?
R
Deb
Deb
60%
disomog
60%
disomog
0
0
0
Contr
. Ins.
0
Contr
. Ins.
?
?
S
OK
OK
100%
100%
0
0
2%
0
Contr
. Ins.
?
BondMax
0
Neg
PR
0
Metodica
SP1/1E2
Ventana
Nor
ER
Nor
PR
Pos
ER
Pos
PR
Neg
ER
TV
OK
OK
100%
100%
0
A
OK
-
100%
disomog
100%
++
C
OK
OK
100%
disomog
D
Deb
Deb
E
Deb
F
G
Neg
PR
Deb
ER
Deb
PR
Metodica
0
2%
2%
SP1 / 636
Polimero
DAKO
0
Deb
pos
?
2%
deb
100%
deb ?
SP1/Ab8
ultravision
100%
0
0
3040%
?
0
?
Vector
Polimero
DAKO
50%
disomog
100%
0
Contr.
Ins.
0
0
Contr
. Ins.
0
Contr
. Ins.
SP1/Ab8
Bond-max
-
90%
disomog
100%
0
0
<5%
0
6F11/1A6
Bond-max
OK
OK
100%
100%
disomog
0
0
2%
0
Contr
. Ins.
SP1/ 1E2
Ventana
-
-
100%
90%
debole
0
0
2%
0
SP1/ 1E2
Ventana
Nor
ER
Nor
PR
Pos
ER
Pos
PR
Neg
ER
T
V
OK
OK
100%
100%
0
H
OK
OK
100%
100%
disomog
0
I
Deb
OK
100%
disomog
100%
Deb
ER
Deb
PR
0
2%
2%
SP1 / 636
Polimero
DAKO
0
2%
0
SP1 /1E2
Ventana
0
Contr
. Ins.
0
Contr
. Ins.
SP1 / 636
Polimero
L
OK
np
100%
disomog
100%
disomog
0
0
2%
0
Contr
. Ins.
6F11 / 636
Bondmax
N
Deb
OK
100%
100%
0
0
2%
0
Contr
. Ins.
SP1/1E2
?
O
OK
OK
100%
100%
0
0
2%
0
Contr
. Ins.
P
OK
OK
100%
np
2%
0
2%
0
Contr
. Ins.
?
?
R
Deb
Deb
60%
disomog
60%
disomog
0
0
0
Contr
. Ins.
0
Contr
. Ins.
?
?
S
OK
OK
100%
100%
0
0
2%
0
Contr
. Ins.
?
BondMax
0
Neg
PR
0
Metodica
SP1/1E2
Ventana
PR normal breast
ER normal breast
ER
PR
ER
ER Low expressing
PR +ve ?
ER
ER
PR-ve
Statement 14. Scelta del campione per la
determinazione dei fattori prognostico
predittivi
E’ necessario che l’ inclusione scelta per la
determinazione dei parametri biologici includa
anche parenchima mammario non neoplastico in
tutti i casi in cui ciò sia possibile.
Statement 15. Scelta del campione per la
determinazione dei fattori prognostico
predittivi
La valutazione dei parametri biologici (assetto
recettoriale, stato di HER2 e Ki-67) deve
essere effettuata anche sulle biopsie preoperatorie se è prevista terapia neo-adiuvante
e sulle biopsie di recidive e metastasi
Statement 16. Scelta del campione per la
determinazione dei fattori prognostico
predittivi
Nel caso di neoplasie multiple, la
determinazione dei parametri biologici va
effettuata su tutte le lesioni solo se di diverso
istotipo o grado
Statement 17. Determinazione sulle neoplasie
in situ di fattori prognostico predittivi
La determinazione dell’assetto recettoriale (ER/PR)
deve essere effettuata anche su neoplasie intraduttali
Statement 18. Determinazione dei recettori
ormonali
Il referto deve riportare il clone utilizzato per la
determinazione immunocitochimica dei recettori
La valutazione dell’assetto dei recettori ormonali
deve essere espressa in valori percentuali
indipendentemente dalla intensità di colorazione
Statement 19. Determinazione dei
recettori ormonali
La valutazione dell’assetto recettoriale deve
corrispondere alla espressione media di
recettori dell’ intera sezione esaminata
Statement 20. Determinazione dei recettori
ormonali
Il controllo positivo interno deve mostrare una
colorazione eterogenea delle cellule luminali
normali, con cellule non colorate accanto a cellule
debolmente colorate e a cellule intensamente
colorate.
Una colorazione limitata a poche cellule e di uguale
intensità può essere dovuta ad una scarsa
sensibilità della reazione. Le cellule mioepiteliali e i
fibroblasti rappresentano un utile controllo negativo
interno: una loro colorazione per quanto debole è
segno di aspecificità della reazione
Conclusions
• The pathology report of breast cancer is the
choice of adjuvant therapy
• The report must be complete and accurate –
in the diagnosis and in the assessment of
prognostic/predictive parameters
• Pathologists should be more and more aware
of their role in the management of patients
with breast carcinoma
Conclusions
• Good laboratory practice
• Technical validation
• Clinical validation
– Correlation with outcome
• Internal and external quality control
programs