Evaluation of Discordance Rate of HER2, ER, PR Receptors Status between Primary Breast Cancer and Distant Metastasis or Locoregional Recurrences

2. 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 Medicine
Ain Shams University
2014

3. 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

4. Figure: (1) Breast cancer incidence mortality.
Review of Literature

5. 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).
Review of Literature

6. 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.
Review of Literature

7.  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.
Hormonal receptors and HER2 in breast
cancer
Review of Literature

8.  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%.
Hormonal receptors and HER2 in breast
cancer
Review of Literature

9.  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.
Hormonal receptors and HER2 in breast
cancer
Review of Literature

10. 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)
Hormonal receptors and HER2 in breast
cancer
Review of Literature

11.  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.
Hormonal receptors and HER2 in breast
cancer
Review of Literature

12.  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.
Hormonal receptors and HER2 in breast
cancer
Review of Literature

13.  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

14. 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

15. 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

16. STUDY DESIGN
In 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

17. 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

18. Patients & Methods
STUDY DESIGN (Cont..)
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.

19.  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
STUDY DESIGN (Cont..)

20. STUDY DESIGN (Cont..)
Patients & Methods
Figure: (2) Allred scoring guidelines

21. 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
STUDY DESIGN (Cont..)
Figure: (3): ASCO/CAP guidelines for HER2 assay using IHC

22.  IHC result of 2+ is considered equivocal and FISH is
performed using the PathVysion HER-2 DNA Probe Kit.
Patients & Methods
STUDY DESIGN (Cont..)
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

23. 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

24. Patients’ Characteristics
Results
Patients characteristics N. Percent (%)
Age
Mean 49.70
SD 9.900
Min. 29
Max. 70
Menopausal status
Premenopausal 26 41.9%
Postmenopausal 36 58.1%
Neoadjuvant therapy
No 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 groups
I 2 3.2%
II 27 43.5%
III 33 53.2%
Table (1): Patients’ Characteristics

25. Results
Adjuvant therapy N.
Percent
)%(
Adjuvant anthracycline based CTH
No 12 19.4%
Yes 50 80.6%
Adjuvant trastuzumab
No 58 93.5%
Yes 4 6.5%
PORT
No 10 16.1%
Yes 52 83.9%
Adjuvant Hormonal treatment
No 27 43.5%
Yes 35 56.5%
Recurrence N.
Percent
)%(
Overall
Loco-regional 47 75.8%
Systemic 15 24.2%
Table (1): Patients’ Characteristics (cont…)

26. Discordance Rates
ER 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

27. Results
Figure (5) : Showing ER discordance rate.

28. 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).

29. Figure (6): Showing PR discordance rate.
Results

30. 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).

31. Results
Figure (7): Showing HER2 discordance rate.

32. 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

33. 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

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

35.  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

36. Results
Figure (10): Showing the relationship between the site of
recurrence (locoregional vs. systemic) and overall receptors
discordance.
Locoreginal vs. Systemic Recurrences

37.
ER Discordance
X2
P
value
Sig
No Yes
Was +ve
&becam
e –ve
Was -ve
&becam
e +ve
Adjuvant
Hormonal
treatment
No
N. 23 4 1 3
1.650 0.008 S∗∗
Row % 85.2% 14.8% 3.7% 11.1%
Yes
N. 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

38.
PR Discordance
X2
P
valu
e
Sig.
No Yes
Was +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%
Effect of adjuvant systemic treatment on receptors
discordance.
Table (3): Relationship between PR discordance and Adjuvant Hormonal treatment
∗ Chi square Test (X2)
∗∗N S: Non-Significant
Results

39.
HER2 Discordance
X2
P
value
Sig
No Yes
Was +ve
became
–ve
Was -ve
became
+ve
Adjuvant
Anthracycli
ne -based
CTH
No
N. 12 0 0 0
1.894 0.32 NS∗∗
Row % 100.0% 0.0% 0.0% 0.0%
Yes
N. 43 7 5 2
Row % 86.0% 14.0% 8.1% 3.2%
Effect of adjuvant systemic treatment on receptors
discordance.
Table (4): Relationship between HER2 discordance and adjuvant
Anthracycline-based chemotherapy
∗ Chi square Test (X2)
∗∗ NS: Non-Significant
Results

40.
HER2
Discordance
X2
P value Sig.
No Yes
Adjuvant
trastuzumab
No
N. 53 5
6.397 0.011 S∗∗
Row % 91.4% 8.6%
Yes
N. 2 2
Row % 50.0% 50.0%
Table (5): Relationship between HER2 discordance and Adjuvant trastuzumab
Effect of adjuvant systemic treatment on receptors
discordance.
∗ Chi square Test (X2)
∗∗ S: Significant
Results

41.  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

42.  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

43. 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

44.  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

45.  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

46.  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

47.  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

48.  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

49.  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

50.  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