Current issues in diagnostic breast pathology

Rosemary A Walker,1 Andy Hanby,2 Sarah E Pinder,3 Jeremy Thomas,4
Ian O Ellis,5 National Coordinating Committee for Breast Pathology Research
Subgroup, On behalf of members of the National Coordinating Committee for
Breast Pathology
ABSTRACT
On behalf of the NHS Breast Screening Programme
Pathology Coordinating Group we present
recommendations for terminology and diagnostic criteria
for a number of key areas of practice in breast pathology
where terminology can be confusing and where accurate
communication will ensure appropriate clinical
management. These recommendations cover columnar
cell lesions and the spectrum of changes that can be
seen in these epithelial proliferations, lobular neoplasia,
micrometastases and isolated tumour cells in axillary
lymph nodes, the use of basal/myoepithelial markers in
diagnostic practice and oestrogen receptor testing in
ductal carcinoma in situ.
INTRODUCTION
The research subgroup of the NHS Breast Screening
Programme (NHSBSP) Pathology Coordinating
Group have compiled overviews and recommendations
for topics that were either not considered or
had minimal discussion in NHSBSP publication
number 58 Pathology Reporting of Breast Disease.
These will be included as appendices in the pending
revision of the non-operative reporting guidelines.
In conjunction with NEQAS the HER2 reporting
guidelines have been updated and published:Walker
RA, Bartlett JM, Dowsett M, et al. HER2 testing in
the UK: further update to recommendations. J Clin
Pathol 2008;61:818e24.
These topics are emerging issues in diagnostic
breast pathology and are presented below as a series
of short monographs.
COLUMNAR CELL LESIONS: NHSBSP
COORDINATING GROUP RECOMMENDATIONS FOR
TERMINOLOGY AND DIAGNOSTIC CRITERIA
Background
In recent years there has been growing interest and
awareness of epithelium within breast biopsies
having a columnar morphology. One of the common
accompaniments of this change is the presence
of secretions within lumina, which are often
distinctly eosinophilic and associated with microcalcifications.
1 These microcalcifications are detectable
at mammography and consequently more of
these lesions are being detected with the introduction
and expansion of breast screening programmes.
The diverse terminology employed for this
epithelium, its increased detection at screening and
the uncertainties regarding its biology continue to
cause concern among both diagnostic breast
pathologists and their clinical colleagues in the
breast care team. In this document, we present
a proposal for a simplified terminology for lesions
with columnar epithelium and histological criteria
for recognising these, and recommendations for
classification using the ‘B’ grading system in core
biopsies. These proposals are not set in stone and
may change as more knowledge is acquired
regarding the pathobiology of these lesions and
their relationship to malignancy.
Terminology
It should be noted that a columnar/flat morphology
is often seen in the epithelium of benign breast
lesions outside the columnar change/flat epithelial
atypia (FEA) spectrum and in cytological preparations
from a number of conditions, for example,
intraductal papillomas.2 Tall columnar cells are also
a feature of a number of more unusual carcinoma
variants, for example, a tumour recently described
as resembling the tall cell variant of papillary
thyroid carcinoma.3
Here we refer to a group of lesions deduced by
several authors to lie within the constellation of
fibrocystic change.4 5 Within this group, a more
focused spectrum of lesions has been delineatedd
namely, columnar cell change (CCC), CCC with
hyperplasia, CCC with atypia and columnar cell
hyperplasia with atypia.6 The morphology of those
with atypia corresponds to FEA, as detailed in the
latest WHO classification.7
CCC5 8e10 has been otherwise variously described
and/or illustrated over the years and lesions with
attributes of columnar lesion have been referred to
under a great diversity of names.1 4 7 11e23 Some of
these terms are detailed in figure 1. However, in
assessing these it is worth noting, as Ho et al
comment, that ‘one must be extremely careful
when comparing outcome of FEA and its equivalents
in the literature, without first having determined
if authors are referring to the same lesion’.23
This statement equally applies to all forms of the
overlapping columnar cell lesions (CCLs).
The proposed ductal intraepithelial neoplasia
(DIN) spectrum described by Bratthauer et al
ranges from usual type ductal hyperplasia through
to high-grade ductal carcinoma in situ (DCIS),24
although molecular studies do not support this as
a continuum and this system of classification is not
widely used. The territory mapped out relevant to
the present discussion is the DIN 1-flat type which
equates to FEA.24
More recently, terminological practice has been
generally simplified (figure 2), reflecting current
guidelines.
1Cancer Studies and Molecular
Medicine, University of
Leicester, Leicester, UK
2Academic Unit of Pathology,
Leeds University, Leeds, UK
3Academic Oncology/Breast
Pathology, King’s College
London, London, UK
4Department of Pathology,
Western General Hospital,
Edinburgh
5Molecular Medical Sciences,
University of Nottingham,
Nottingham, UK
Correspondence to
Dr Ian O Ellis, Molecular Medical
Sciences, University of
Nottingham, Department of
Histopathology, Nottingham City
Hospital, Hucknall Road,
Nottingham NG7 1DD, UK;
ian.ellis@nottingham.ac.uk
Accepted 1 February 2012
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Microscopic appearances of CCLs (Table 1)
CCCs without atypia
The classic CCL is comprised of lobular acini lined by epithelial
cells that are tall and snouted in a manner similar to that
observed in tubular carcinoma. Commonly this is associated
with luminal secretions and/or microcalcifications (figure 3A,B).
If there is a piling up of several layers the term ‘columnar cell
hyperplasia’ is used, assuming that the stratification is real
(figure 3D) rather than artefactual as a consequence of crosscutting
(figure 3C). There is morphological diversity within
these groups, for example, the hyperchromasia of the nuclei can
vary, as well as nuclear shape and the ‘tallness’ of the cells; thus
in some cases some lesions are more cuboidal than columnar.
Flat epithelial atypia
If cytological atypia is present in CCC or columnar cell hyperplasia,
the lesions should be classified as FEA (figure 2).8 33 There
is, however, morphological diversity in this group of lesion; in
some cases the atypia manifests as relatively uniform rounded
evenly spaced nuclei with a similar cytomorphology to that
displayed by the cells of low and some intermediate grade DCIS
(figure 4C). In this form of FEA, polarisation of the cells may be
lost. Nuclei are often more centrally placed. In others, distinct
nuclear pleomorphism is evident, falling short of high nuclear
grade but, equally, without the relative nuclear uniformity
described above (figure 4A,B). Finally, some FEA display
a distinctly endometrioid appearance with tightly packed tall
hyperchromatic fusiform nuclei (figure 4D).
Exclusions
Atypical ductal hyperplasia
FEA by definition does not have a complex architecture; if
micropapillary or cribriform structures are seen, the diagnosis of
atypical ductal hyperplasia (ADH) or low-grade DCIS should be
considered.34 The process may involve more than one terminal
duct lobular unit. Sporadic atypical architecture may be widely
spaced. Rather than result in overdiagnosis of DCIS, it is proposed
that the current size criterion guidelines for differentiating DCIS
and ADH (>2 mm or >2 duct spaces)25 be relaxed and the term
FEA be applied under these circumstances. Whether most FEA is
biologically equivalent to most ADH is, as yet, uncertain but
likely. In practice, FEA is often seen merging with the more
elaborate architecture of ADH (figure 5) and DCIS, demonstrating
the close relationship of FEA to these lesions. Lesions which fulfil
the criteria for low-grade DCIS by showing $2 ducts fully
involved by an architecturally and cytologically atypical process
without intervening gaps of non-atypical epithelium should still
be regarded as such and not as FEA.
Ductal carcinoma in situ
Where flat epithelial proliferative epithelium within a terminal
ductal lobular unit (TDLU) possesses high cytonuclear grade
nuclei, the lesion should be categorised as high-grade flat DCIS,
not FEA (figure 6). Care should be taken in the diagnosis of flat
high-grade DCIS in core biopsies and it may be prudent to
categorise this as B4 suspicious in such limited samples.
Differential diagnosis
It should be borne in mind that there are many phenomena with
low or ‘flat epithelium’ that do not fall under the category of the
CCLsdfor example, the tall monolayered epithelium of in situ
papillary neoplasia.
Apocrine change
Apocrine epithelium shares with columnar change the presence
of apical snouts and sometimes associated secretions. However,
the cytoplasm of apocrine cells is typically copious and granular
and, unlike most columnar cells, nucleoli are readily seen.
Apocrine cells are usually androgen receptor positive but
oestrogen receptor (ER) and progesterone receptor (PR) negative;
the converse is true for columnar epithelium.
Lactational change
Another lesion that may be mistaken for FEA is focal lactational
change, which may appear both monolayered and mildly
cytologically atypical with enlarged hyperchromatic nuclei.
Typically, the epithelial cells are more cuboidal than tall and
the foamy appearance to the cytoplasm produced by finely
divided lipid should alert the pathologist to this diagnosis
(figure 7).
Markers in CCLs
Producing a clear idea of the marker profile in columnar lesions is
bedeviled by the variety of terminology used in different
Figure 1 Varied terminology-related lesions with columnar and flat
epithelium. ADH, atypical ductal hyperplasia; DCIS, ductal carcinoma in
situ; DIN, ductal intraepithelial neoplasia.
Figure 2 Most simple classification of columnar lesions (after Schnitt
and Vincent-Salomon6). DCIS, ductal carcinoma in situ.
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publications and the uncertainty about their equivalence. What
follows is a distillation of what is known, under the broad
umbrella of the names indicated above.
Unlike the normal breast and usual ductal hyperplasia (UDH)
where ER and PR staining is heterogeneous and limited to about
10e15% of cells,25 in CCC and related lesions there is extensive
and uniform positivity of the nuclei of all lesional cells.4 5 15 20
Most cells stain positively for keratin 1915 and osteoprotegerin26
and a high proportion stain for cyclin D1.15 Kusama et al
demonstrated a Ki67 labelling index of 0.3% in columnar lesions
versus 13.7% in adjacent DCIS.18 Unlike UDH, the lesional cells
do not express basal markers such as CK5/6.27 As indicated
above, immunohistochemistry (IHC) may be useful in separating
apocrine from columnar epithelium, the former being
Figure 3 Columnar cell change
without atypia (A-D) Columnar cell
change affects lobular units which show
variably dilated acini often with
microcystic change and calcification
(figure 3A, B). The lining epithelial
morphology varies from low cuboidal to
the classic columnar type with apical
snouts (3C) In more florid cases the
epithelium is multi-layered and
classified as columnar cell hyperplasia
without atypia (3D).
Table 1 Comparison of pathological features of the spectrum of entities from columnar cell change through to ADH/DCIS
Feature
Diagnosis
Columnar cell change Columnar cell hyperplasia FEA ADH/DCIS
Topography TDLU, acini may be mildly
dilated or of normal size
TDLU, acini may be mildly
dilated or of normal size
TDLU, often microcystically
dilated acini
TDLU 6 adjacent ducts
Shape of acinar spaces Irregularly shaped luminal margin Irregularly shaped luminal margin Often rounded acinar spaces,
with smooth inner margin
Often rounded acini, but with
complex structures extending
into lumen (see architecture,
below).
Architecture Flat Tufts and mounds Flat or tufted, not complex Complex with micropapillary
or cribriform structures
Stratification/multilayering Not present Present May be present May be present
Luminal secretions often
with microcalcification
Present Present Present May be present
Nuclear size Small to medium Small to medium Small to medium Small to medium
Nuclear shape Oval, elongated Oval, elongated Often, but not always, rounded Rounded
Nuclear texture Bland Bland Speckled chromatin pattern
may be present
Speckled chromatin
pattern common
Pleomorphism* Uniform Uniform Uniform to moderately
pleomorphic
Uniform
Position of nuclei within cell Basally placed Basally placed Often central Central
Nucleoli Not conspicuous Not conspicuous Not conspicuous, but may
be evident
Not conspicuous, but may
be evident
Mitoses Generally absent Generally absent Generally scarce Generally scarce
Extent May be focal or extensive May be focal or extensive May be a focal area
within background of
non-atypical CCL
May be focal area within
background of non-atypical
CCL. By definition ADH is
small/microfocal
*If marked pleomorphism, the lesion does not fall with the spectrum of CCLs but should be regarded as high-grade DCIS.
ADH, atypical ductal hyperplasia; CCLs, columnar cell lesions; DCIS, ductal carcinoma in situ; FEA, flat epithelial atypia; TDLU, terminal ductal lobular unit.
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androgen receptor positive and ER and PR negative. The utility
of GCF15, typically positive in apocrine epithelium, in making
this distinction has yet to be documented in the literature. It is
worth noting that McLaren et al found that patients with ER
negative CCLs were at increased risk of malignancy compared
with those whose lesions were ER positive,23 but as yet there are
no confirmatory studies.
In conclusion, at present the main use for IHC is in the
differential diagnosis of columnar from some apocrine lesions.
Significance of CCLs
CCLs of the breast encompass a morphological spectrum which
may coexist within a wide range of lesions that may include in
situ and invasive carcinoma.9 However, the overall biological
significance of these lesions is unknown.28 There is supporting
evidence for a precursor role including an association with
tubular carcinoma9 12; the finding that these lesions are found
more commonly in cancerous than non-cancerous breasts17; are
often continuous with cancerous lesions18; commonly coexist
with lobular in situ neoplasia22; and share similar cytological
characteristics and immunohistochemical profile with coexistent
malignancies.15
Figure 5 Atypical ductal hyperplasia. Flat epithelial hyperplasia,
particularly when florid can show both cytonuclear and architectural
feature of low grade DCIS but fail to have sufficcent extend for
classification as DCIS. The diagnosis of atypical ductal hyperplasia
arising in a background of FEA can be made in these circumstances.
Figure 6 High-grade ductal carcinoma in situ may show mono- or
oligo-layering within the inner surface of an involved duct. High-grade
nuclear pleomorphism such as this is not seen in flat epithelial atypia.
Figure 4 Flat epithelial atypia (4 A-D)
Flat epithelial atypia usually shows
more exajurated involvement of the
breast parenchyma (4A). The cells
show a loss of nuclear polarity but may
retain a columnar morphology (4B). The
nuclei are often more rounded and less
ovoid than in columnar cell change
(4C0. The degree of atypia can become
more marked but is not high grade (4D)
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Despite the above, the certainty and speed of progression of
these lesions to malignancy is unknown. Eusebi et al11 discovered
25 cases (0.26%) of what was called low-grade clinging
carcinoma of flat type, but which appears morphologically
equivalent to FEA. During an average follow-up interval of
19 years, none of the 25 women with low-grade clinging carcinoma
of flat type developed invasive carcinoma and only one
had a recurrence, which was described as consisting of low-grade
clinging carcinoma of flat type.29
At a more fundamental level, there is evidence that, in general,
there is a progressive accumulation of allelic damage in FEAthrough
to DCIS and invasive carcinoma, implying a molecular continuum
from at least some lesions with a columnar morphology (which is
not the case for UDH and carcinoma).28 30 Despite the very limited
follow-up data to date and the need for more evidence, this implies
that the biological progression of an individual columnar lesion
may be slow. However, it seems very likely that FEA is one of the
earliest forms of neoplastic change in the breast.
CCLs in breast core biopsies
Cores bearing CCLs are typically sampled for the histological
assessment of mammographic microcalcifications. As for other
such specimens, these should be examined at multiple levels (at
least three). If CCC or hyperplasia only is found without atypia,
the lesions should be regarded as within the constellation of
fibrocystic change and categorised as B2, benign.
CCLs with atypia should be regarded as FEA and classified as
B3, of uncertain malignant potential. Lesions with more
complex architecture should also be regarded as an atypical
epithelial proliferation and also regarded as B3, of uncertain
malignant potential.
As for all such screen-detected lesions, multidisciplinary
discussion should be undertaken to correlate radiological, clinical
and histopathological findings. Data on risk of finding adjacent
associated malignancy are extremely limited.
CCLs in surgical excision specimens
Thorough sampling and histological examination of surgical
specimens bearing FEA should be performed to search for more
established neoplasia. In association with some DCIS and/or
invasive carcinoma, FEA may be present and may be extensive
and/or may extend to the margins of the specimen. This is
particularly problematic for lesions which are well recognised as
being associated with FEA such as tubular carcinoma9 and, in
such cases, it may be uncertain as to whether the CCL represents
the precursor process. There is a very limited evidence base
for guidance but, at present, it is recommended that whole
tumour size (DCIS plus invasive carcinoma) and margin status
should include only those areas regarded as established DCIS or
invasive tumour using conventional criteria.
Reproducibility of current classification of CCLs
The reproducibility of diagnosis of CCL varies in the published
literature. One study looking at the assessment of images by
a mixed population of assessors showed poor agreement.31
Another demonstrated ‘excellent agreement’ for a specified task
within the CCL group after a PowerPoint directed training
session undertaken by a group of pathologists with an interest in
breast pathology.32 Agreement was slightly better for determining
the absence of FEA (92.8%, 95% CI 84.1% to 97.4%) than
for determining its presence (90.4%, 95% CI 79.9% to 96.7%).
The latter authors concluded that the diagnosis of FEA and its
distinction from CCLs without atypia was highly reproducible if
the presently available diagnostic criteria were adhered to. This
simplified classification in the latter study forms the basis of the
recommendations presented here.
Issues of poor reproducibility can confound diagnosis and lead
to inconsistent patient care. This is more likely when complex
and diverse terminology with shades of possible interpretations
exist. This is no more apparent than in the case of lesions
possessing columnar epithelial morphology and is the strongest
argument for the simplified classification of these lesions
presented in this document.
IN SITU LOBULAR NEOPLASIA: NHSBSP COORDINATING
GROUP OVERVIEW AND RECOMMENDATIONS
Lobular carcinoma in situ (LCIS) was first described in 1941 by
Foote and Stewart33 and was considered to be akin to DCIS with
Key points and recommendations
< The terms columnar cell change and columnar cell hyperplasia
are regarded as benign lesions falling within the constellation
of fibrocystic changes and in core biopsy should be classified
as B2, benign.
< Columnar cell lesions with cytological atypia should be
regarded as FEA and, in a core biopsy, categorised as B3, of
uncertain malignant potential.
< Sporadic atypical architecture may be widely spaced. Rather
than result in overdiagnosis of DCIS, it is proposed for the
current guidelines that the size criterion for differentiating
DCIS and ADH (>2 mm or >2 duct spaces)25 be relaxed and
the term FEA be applied under these circumstances. In needle
core biopsy samples these should be regarded as B3, of
uncertain malignant potential.
< Columnar cell lesions with high cytonuclear grade should be
regarded as flat high-grade DCIS.
Figure 7 (A) Lactational changes can
be mistaken for flat epithelial atypia and
(B) in some rare variants show distinct
cytological atypia. The epithelium tends
to be cuboidal and the presence of
foamy clear cytoplasm should alert one
to this diagnosis.
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regard to clinical behaviour, with the recommended management
being mastectomy. Subsequently, lobular neoplasia, the
term introduced by Haagensen et al,34 was felt to differ from
DCIS, being a risk indicator of subsequent development of breast
cancer34e36 rather than a true precursor, so radical surgical
treatment fell out of favour. The advent of mammographic
screening, further follow-up studies and molecular analysis of
lobular neoplasia has resulted in the need to re-address its
significance and management.
Terminology
Atypical lobular hyperplasia (ALH) and LCIS have been considered
distinct entities. They are both characterised by a proliferation
within the TDLUs of poorly cohesive, monotonous
cuboidal or polygonal cells with clear or light cytoplasm.
Intracytoplasmic lumina may be present. Mitotic figures
are infrequent. Pagetoid spread of cells between the surface
epithelial cells and the basement membrane may be present. The
differentiation between the two forms relates to the extent and
degree of distension of acini, but this is subject to intra- and
inter-observer variability. Because of this the term ‘lobular
neoplasia’ or ‘in situ lobular neoplasia’ was introduced, which
does not differentiate between ALH and LCIS.
A further system proposed is ‘lobular intraepithelial
neoplasia’37 with three subdivisions that relate to morphology
and predicted clinical outcome. This grading system requires
validation and has not been endorsed by the WHO at the
present time.38
‘Pleomorphic lobular carcinoma in situ’ is a more recently
described entity39e42 in which the cells show more marked
pleomorphism with larger nuclei. Central necrosis and calcification
may be present. Distinction from high-grade DCIS may,
on occasions, be difficult. Comedo-type necrosis can be present
in LCIS that has the typical cytological and architectural
features42 and, although atypical, this should not be diagnosed
as pleomorphic LCIS.
Other variants that have been described include endocrine,
apocrine, histiocytoid and signet ring lobular neoplasia,43 mainly
based on cytonuclear features.
Frequency
It is difficult to assess the frequency of lobular neoplasia since there
are no specific clinical, mammographic and macroscopic features.
It was considered to be present more frequently in the 40e50 age
group34 but the incidence in postmenopausal women is increasing,
probably due to detection by mammographic screening. The
incidence in otherwise benign biopsies is reported as between 0.5%
and 3.8%.34 44 It can be both multifocal and bilateral.
Immunohistochemical analysis
The characteristic alteration of lobular neoplasia is the lack of
expression of the cell adhesion molecule E-cadherin, which is
consistently present on the membranes of normal luminal
epithelial cells and is also lost in invasive lobular carcinoma
(ILC).45e47 Alterations are seen in both classical and pleomorphic
lobular neoplasia and immunohistochemical analysis of
E-cadherin can aid the diagnosis of solid in situ proliferations of
indeterminate nature.48e50 Lack of E-cadherin supports a diagnosis
of lobular neoplasia but, if a mixed pattern of staining is
present, then it should be reported as combined DCIS and
lobular neoplasia.50 Negative markers can, however, cause
problems in interpretation. p120 catenin is a member of the
cadherin-catenin complex that has a cytoplasmic staining
pattern in lobular neoplasia and has been found to be useful in
separating lobular neoplasia from low-grade DCIS.51
High molecular weight cytokeratins identified by the antibody
34bE12 have been reported to be consistently present in
lobular neoplasia and could be used to differentiate it from
DCIS,52 but a subsequent report considered staining to be an
artefact.53 This antibody should be used with caution.
Lobular neoplasia consistently shows positivity for ER and
PR, including the pleomorphic variant.41 47 HER2 amplification
and overexpression have been found in pleomorphic LCIS.41 42
Molecular studies
The CDH1 gene that encodes for E-cadherin is inactivated in
LCIS and ILC through both genetic (deletions and inactivating
mutations) and epigenetic (gene promoter methylation) mechanisms.
54e56 Concurrent mutations have been identified in LCIS
and ILC.46 Mutations have also been found in ALH.56
Comparative genomic hybridisation analysis has shown that
similar chromosomal changes are present in ALH and LCIS.57
Array comparative genomic hybridisation and mitochondrial
DNA analyses have confirmed similar genetic alterations
between matched lobular neoplasia and ILC.58 59
Overall, the molecular data provide strong evidence that
lobular neoplasia is a non-obligate precursor of ILC.
Differential diagnosis
The main problems relate to poor fixation in a surgical specimen,
differentiating low-grade solid DCIS from lobular neoplasia and
pleomorphic LCIS.
In larger surgical specimens poor fixation can lead to artefactual
discohesion within lobular units, resulting in an overdiagnosis
of LCIS. This is more of a problem in mastectomies
that have not been sliced sufficiently in the fresh state.
Differentiating low-grade solid DCIS from lobular neoplasia
can be difficult in both surgical specimens and core biopsies and
the use of E-cadherin staining can be particularly helpful.48e50
Coexistent low-grade DCIS and lobular neoplasia is not rare and
a mixed pattern of E-cadherin staining will be seen in these
circumstances. Cancerisation of lobules by DCIS can also cause
problems and again E-cadherin staining is of value.
Pleomorphic LCIS39e42 can be difficult to differentiate from
high-grade DCIS due to the degree of pleomorphism, the presence
of necrosis and calcification, and has most certainly been
classified as DCIS previously. Pleomorphic LCIS should be
considered if there is poor cellular cohesion along with these
other features. Again E-cadherin staining can be invaluable.
Since it is not possible reliably to assess the degree or extent of
lobular changes in core biopsies, providing that DCIS has been
excluded, the lesion should be reported as B3, of uncertain
malignant potential, and recorded as lobular neoplasia, with no
attempt to distinguish ALH and LCIS.
Significance
The significance of the diagnosis of lobular neoplasia in a needle
core biopsy relates to the risk of there being associated invasive
carcinoma (or DCIS) present at the time of the biopsy (see
Management). When identified within a surgical biopsy/excision
specimen, the questions of concern are different. These are: (1)
What is the risk of subsequent development of invasive carcinoma?
(2) Is lobular neoplasia a precursor lesion of invasive
disease? (3) Does lobular neoplasia affect the risk of recurrence
following breast conserving therapy?
It has been recognised for a long time that lobular neoplasia is
an indicator of increased risk of developing invasive cancer,34e36 44
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with the RR differing between ALH (3e53)60e62 and LCIS
(8e113).34 36 44 63 64 The increased risk has been found in some
reports to be evenly distributed between both breasts,34 64 65
although Page et al62 found invasive carcinoma to be three times
more likely to arise in the breast with ALH than the contralateral.
Collins et al66 found the risk of developing an invasive cancer to
be greater for premenopausal women with ALH than ADH,
whereas SEER data64 show an increased incidence after the
menopause.
The evidence that lobular neoplasia could be a non-obligate
precursor lesion comes from molecular and epidemiology studies.
As described above, the genetic profiles of ALH and LCIS are
similar to each other and to those of ILC.54e59 That there is
a greater risk of invasive cancer in the ipsilateral breast62 66 67 and
that the invasive cancer is more likely to be lobular than ductal35
67 also indicate that lobular neoplasia could be a non-obligate
precursor. Although there are no long-term follow-up studies of
pleomorphic LCIS, the small-size series that have been published
have shown a higher incidence of associated invasive disease,
usually ILC, which is suggestive of a precursor lesion.42
There is general agreement from published studies that the
presence and extent of lobular neoplasia, including presence at
the margins, does not increase the risk of recurrence following
breast conserving surgery,68e71 although the NSABP study69
excluded cases of pleomorphic LCIS (described as DLCIS).
Management
Needle core biopsy
Issues relating to lobular neoplasia in needle core biopsies have
recently been reviewed.72 73 The EUSOMA Working Group74
considered lobular neoplasia to be most frequently a coincidental
finding in a core biopsy and therefore advised that multidisciplinary
discussion was essential to determine management, as is
advocated by others.75 Diagnostic surgical excision of lobular
neoplasia has been advocated.76 A recent review of the literature
revealed an upgrade of 20% for LCIS and 13% for ALH to
carcinoma when excised.77 Concerns have been raised about
underestimation of cancer,77e81 even with stereotactic vacuumassisted
biopsy,79 and this has led to the recommendation of
diagnostic surgical excision for all such lesions from some
groups.73 It must be appreciated that much of the data is
retrospective and that not all studies have considered radiological-
pathological discordance as a factor resulting in upgrade, as
found by some.75 82 What is required are large prospective
studies with all factors included.
There is general agreement, although limited robust data, that
pleomorphic LCIS should be subjected to therapeutic excision; in
essence, treated as DCIS and therefore categorised as B5a on
needle core biopsy. In one series of 12 cases diagnosed on needle
core biopsy, ILC was found in 3 on subsequent excision.83 There
is a need for larger studies to confirm that this does represent
a more aggressive disease.
Surgical excisions
The presence and extent of lobular neoplasia in therapeutic
excisions should be reported as well as its presence at margins.
At present further surgery is not recommended if the invasive
cancer is excised.68e71
If lobular neoplasia only is seen in a diagnostic excision biopsy
and the clinical/radiologically relevant area has been excised,
then no further surgery is required.
If pleomorphic LCIS is found at excision margins then it
should be treated as would DCIS and further surgery undertaken
to obtain complete excision with appropriate margin of
clearance.
MICROMETASTASES AND ISOLATED TUMOUR CELLS (ITCS):
NHSBSP COORDINATING GROUP OVERVIEW AND
RECOMMENDATIONS
Lymph node status is recognised as being a major prognostic
factor for patients with breast cancer and forms part of staging
systems such as the TNM (tumour, lymph node, metastases)
classification system. That lymph node metastases could be
‘occult’ was recognised over 40 years ago,84 but their significance
is still debated. The introduction of sentinel lymph node biopsy
has raised further issues regarding the importance, or not, of
these ‘occult’ metastases. These relate to their definition; how
they are detected and measured; and their significance in
predicting involvement of non-sentinel lymph nodes and
prognosis.
Definitions
The term ‘occult’ metastasis has been defined as one missed by
initial histological examination and identified on subsequent
assessment, and also as a metastasis identified through additional
evaluation of paraffin-embedded lymph node blocks.85 It
has not been defined by size. Publications referring to occult
metastases are therefore not necessarily comparable with regard
to the size of these metastases. Some earlier studies did use
2.0 mm as the cut-off between micrometastasis and macrometastasis.
86e88 Based on the evidence produced from these, the
5th edition of the AJCC Cancer Staging Manual introduced the
definition of micrometastasis as being #2 mm (pN1a).89 The
sixth editions of the AJCC/UICC staging manuals90e92 further
defined micrometastases to be >0.2 mm but not >2.0 mm and
introduced the term isolated tumour cells (ITC) that are
#0.2 mm:
Key points and recommendations
< Due to problems in assessing the degree or extent of changes
in needle core biopsies, the terms ‘lobular neoplasia’ or ‘in situ
lobular neoplasia’ should be used rather than ‘atypical lobular
hyperplasia’ and ‘lobular carcinoma in situ’ (LCIS). In surgical
specimens, atypical lobular hyperplasia and LCIS should be
distinguished and recorded.
< Lack of expression of the cell adhesion molecule E-cadherin
can aid differentiation from low-grade solid DCIS.
< Pleomorphic LCIS exhibits more marked pleomorphism,
necrosis and calcification. It can be differentiated from DCIS
by lack of E-cadherin but should be managed as DCIS when
diagnosed on needle core biopsy (B5a) and if at surgical
excision margins.
< Lobular neoplasia is an indicator of increased risk of
developing invasive carcinoma, which is greater for LCIS.
< There is evidence that lobular neoplasia is a non-obligate
precursor lesion, based on similarities of genetic profiles with
ILC and greater risk of invasion in the ipsilateral breast.
< Finding of lobular neoplasia in needle core biopsy merits
multidisciplinary discussion and, for the majority, diagnostic
surgical excision.
< Presence of lobular neoplasia at surgical excision margins
should be recorded but does not require re-excision.
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Connolly,93 in discussing changes and problematic areas in the
AJCC Cancer Staging Manual, identified that there could be
differences in interpretation of ITCs in different situations
which would result in different classification of node status. The
European Working Group for Breast Screening Pathology (EWG)
undertook an evaluation of low volume lymph node involvement
in order to test reproducibility of these categories for
distinguishing ITCs and micrometastases.94 The first evaluation
of images from 50 lymph nodes showed only fair reproducibility,
better for micrometastases than for ITCs. Following discussions,
refinements to the definitions were proposed (box 1). The use of
these refinements improved reproducibility between participants.
When these criteria were used by another less specialised
group to categorise the same cases, consistency was achieved
with the experts95 but the level of consistency was still
moderate. A subsequent study to improve interobserver
reproducibility was undertaken led by Turner,96 in which six
experienced breast pathologists examined digital images of
small volume nodal metastases before and after studying
a training programme (criteria in box 2). The EWG then applied
the two interpretations of the TNM definitions and found
that the Turner system had better reproducibility but it may
underestimate the rate of non-sentinel node involvement.97
The evidence suggests that there are problems with using
these definitions, particularly when discriminating between
ITCs and micrometastases which will affect interpretation
of their significance. The TNM definitions of low volume
nodal metastases need to be better formulated with visual
information.
Detection
The three areas that have been considered have been the extent
to which lymph nodes should be examined histologically, the
use of IHC and, to a lesser extent, the use of reverse transcriptase
PCR to identify micrometastases and ITCs.
Histological examination of lymph nodes
How extensively to analyse a lymph node has become a question
raised frequently with the increasing use of the sentinel lymph
node biopsy technique.
There are differences in relation to the initial slicing of the
node; the American Society of Clinical Oncology (ASCO)
guidelines for sentinel lymph node biopsy in early breast
cancer98 recommend slicing through the long axis whereas
NHSBSS Pathology Reporting of Breast Disease99 recommends
slicing the node perpendicular to the long axis. Both advocate
thin slicing and embedding all pieces. When sentinel nodes are
sliced at 2 mm intervals and totally embedded, the probability of
identifying all metastases >2.0 mm is high.85 Cserni100 used
a geometrical model of sentinel lymph node histopathology and
found that sections 1 mm apart should identify metastases
>2 mm. To identify micrometastases, step sectioning with levels
of 250 mm or 200 mm would be required.
A review of the literature101 on the value of using step
sectioning and IHC (see below) found upstaging to be reported
Box 2 Turner study classification rules (from Cserni
et al97)
< Isolated tumour cells and micrometastases are distinguished
by the size of the largest tumour cell cluster, regardless of
microanatomical location within or adjacent to the lymph node
and regardless of the number of clusters or single cells.
< A cluster is a confluent focus of tumour cells touching other
tumour cells.
< Clusters or cells separated by a single benign cell or a spatial
gap are measured as separate clusters, except when
fibroblastic reaction has caused the separation.
< Any lesion composed of non-cohesive cells or clusters not
>0.2 mm represents isolated tumour cells.
< Any lesion with largest cohesive cellular lesion >0.2 mm but
not >2.0 mm represents micrometastasis.
< Mitotic activity is not considered.
< For borderline or indeterminate findings at the two ends of the
spectrum, the lower stage category should be selected.
Micrometastases pN1mi, >0.2 mm, none >2 mm.
May have histological evidence of
malignant activity (proliferation/stromal
reaction) but not a requirement.
Isolated tumour cells (ITC) Single tumour cells or small clusters of
cells no more than 0.2 mm in greatest
dimension. Usually detected by immunohistochemistry
or molecular methods,
verified by H&E section. Do not typically
show proliferation/stromal reaction or
penetration of vascular or lymphatic sinus
walls.
pN0dno metastasis histologically.
pN0 (i+) isolated tumour cells.
Box 1 European Working Group study classification rules
(from Cserni et al97)
< Capsular (including intravascular) lesions considered nodal,
and any lesion with nodal and simultaneous extranodal
involvement considered nodal, but lesions outside the node
(afferent lymphatics, perinodal fat) not recorded as nodal
involvement.
< Tumour cells (multiple) localised in parenchyma considered
micrometastasis even if <0 .2=".2" mm="mm" no="no" or="or" p="p" proliferation="proliferation" with="with">stromal reaction.
< Tumour cells localised in vessels or sinuses: if #0.2 mm
isolated tumour cells, if >0.2e2 mm micrometastasis.
< If multiple foci, only largest should be considered.
< Single tumour cells or clusters arranged in a continuous
manner or separated by 2e5 cells should be considered and
measured as one focus and characterised by largest
dimension.
< Cells or clusters arranged in a discontinuous manner and
dispersed homogenously in a definable part of the lymph node
should be considered and measured as one focus.
< Cells, clusters or foci (as defined above) arranged in
a discontinuous manner and dispersed unevenly should be
considered as one if the distance between the clusters or foci
is smaller than the smallest cluster or focus.
< Cells, clusters or foci (as defined above) arranged in
a discontinuous manner and dispersed unevenly should be
considered as distinct and multiple if the distance between
the unevenly distributed tumour cells, clusters or foci is
greater than the smaller cluster or focus and should be
characterised by the largest cluster or focus.
< In cases of doubt, the lower category (isolated tumour cell)
should be given.
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after the former to range from 4.8%102 to 30.7%.103 However, it
was difficult to assess in various studies whether this referred to
macrometastasis or micrometastasis.
Immunohistochemistry (IHC)
Cytokeratin antibodies (eg, Cam5.2, MNF 116, Pan cytokeratin;
AE1/AE3) have been used in many studies to aid the detection
of metastases (macrometastases and micrometastases, ITCs),
often in combination with step sectioning and on multiple
levels in cases with negative H&E findings. Reviews of the
literature101 104 indicate IHC results in upstaging in 2.6e19% of
cases. One study105 found IHC to detect metastases in 4%, 2%
being micrometastases (detectable on H&E section on review)
and 2% being ITCs, and concluded it was of limited value.
Concerns about interpretation of IHC were raised by Roberts
et al106 who found that, as tumour cell numbers decreased, the
ability of pathologists to recognise them also decreased. Other
concerns have been raised about IHC-only detected tumour cells
in lymph nodes.107 In a review of 4066 cases of sentinel nodes
positive only on IHC, there was no association with vascular
invasion, tumour size, tumour type and location but there was
an association with method of biopsy, the frequency increasing
in relation to the degree of manipulation.
Molecular analysis
The predominant method has been reverse transcriptase PCR for
a range of markers (cytokeratin 19, 20, CEA, MUC-1, maspin,
mammoglobin) using either frozen sections or half the sentinel
node. One of the largest series with 123 patients and 146 nodes
by Manzotti et al108 had a high sensitivity but lower specificity
for any marker, with a higher specificity for two of CK19,
maspin or mammoglobin. Molecular analysis has recently been
developed commercially for the intraoperative assessment of
metastases in sentinel lymph nodes109e111 but has not been
evaluated extensively.
Significance
There are two topics of importance: (1) whether micrometastases
and ITCs predict the involvement of non-sentinel
axillary lymph nodes and (2) the prognostic significance of
micrometastases and ITCs.
Predicting non-sentinel lymph node metastasis
The aim of the sentinel node procedure is to reduce the
frequency of axillary node surgery in node negative women and
so reduce morbidity. Identification of sentinel node involvement
is considered an indication for further axillary surgery or radiotherapy,
but the question is whether such treatment is required
if only a micrometastasis is present in the sentinel node. Cserni
et al112 undertook a literature review and meta-analysis of 25
studies published up to 2003 that considered non-sentinel node
metastases associated with sentinel node micrometastasis. They
concluded that the risk of non-sentinel node metastasis was
around 10e15%, lower if sentinel node involvement was
detected by IHC. Viale et al113 found differences in frequency of
non-sentinel node metastases in relation to the size of the
micrometastasis, being less if <1 factors="factors" have="have" mm.="mm." other="other" p="p" that="that">been found to relate to non-sentinel node metastases in the
presence of sentinel node micrometastasis include tumour
size,114e116 grade115 and vascular invasion.116 Since the metaanalysis
undertaken by Cserni et al,112 further publications have
reported differing frequencies in the incidence of non-sentinel
node metastases. In tumours 15 mm or less, no further
involvement was found for cases with ITCs, with 12% of cases
with micrometastases having non-sentinel node involvement.117
Tumour size and type were found to be factors predicting noninvolvement
in the study by Houvenaeghel et al.118 Similar
frequencies of involvement for cases with micrometastases have
been reported in two papers from Holland (19%, 20%),119 120
although there were differences for ITCs (7%, 13%). In a study
confined to ITC positive sentinel lymph nodes, a very low
incidence of non-sentinel node metastases was found and no
axillary recurrence if axillary surgery had not been performed.121
There is sufficient evidence to support the avoidance of
axillary node dissection in cases with ITCs, but there is no
agreement with regard to the further management of the axilla
if micrometastases are identified.
Prognostic significance of micrometastases and isolated tumour
cells (ITCs)
Many of the studies undertaken (reviewed by Cserni et al101)
have considered occult metastases with only a small number
commenting specifically on micrometastasis. Different combinations
of H&E 6 step sectioning 6 IHC have been used.
There is no strong evidence for a survival disadvantage. Some
studies suggest that there is, but within these there are variations
in relation to disease-free and overall survival and
different patient groups. A study with a long follow-up that
considered occult metastases found no difference in survival for
patients with and without these,122 and emphasised the need
for multivariate analysis in such studies. Using data taken from
a cancer registry for a 25-year period, Kuijt et al123 found on
multivariate analysis that patients with micrometastases had
a significantly worse survival than those without, but there
was no pathological review of lymph nodes. The same applies
in two studies based on data from SEER which found the
prognosis for micrometastatic disease intermediate between
N0 and N1124 125 and concluded that a prospective study is
required. A re-evaluation of node negative cases with 20-year
follow-up using IHC identified 23% of cases with metastatic
disease, predominantly ITCs.126 The prognosis of those with
micrometastatic disease was poorer than node negative cases,
which was more apparent after 10 years. Another centre
examining node negative cases after 8 years of follow-up found
13% of cases with micrometastatic disease but there was no
association with outcome.127
USE OF BASAL/MYOEPITHELIAL MARKERS IN BREAST
PATHOLOGY: NHSBSP COORDINATING GROUP OVERVIEW AND
RECOMMENDATIONS
The increasing use of needle core biopsy for non-operative
diagnosis and the nature of lesions identified mammographically
can result in diagnostic difficulties. Interpretation may be helped
by the use of IHC to detect basal/myoepithelial markers. A
recently circulated questionnaire showed that there were variations
in the type and frequency of markers used diagnostically in
the UK and Ireland. This paper summarises current knowledge
of the various markers, discusses the diagnostic areas where they
are of value and makes recommendations for a suitable diagnostic
panel.
Basal/myoepithelial markers
The myoepithelial cell has traditionally been distinguished from
luminal epithelial cells by the presence of smooth muscle fibres.
However, many more proteins have now been identified that are
expressed in myoepithelial cells and these fall into three groups
(smooth muscle-related, cytokeratins and others).
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Smooth muscle-related
< Smooth muscle actin (SMA): antibodies detect actin microfilaments;
good sensitivity but specificity poor since will
detect myofibroblasts.128
< Smooth muscle myosin heavy chain (SMMHC): structural
component of smooth muscle myosin. SM2 isoform is
expressed in breast myoepithelial cells. Sensitivity and specificity
are high with SMMHC being present in periductal and
periacinar myoepithelial cells and not stromalmyofibroblasts,129
although sensitivity reported to be slightly lower than SMA.128
< Calponin: 34 kD polypeptide, modulates actomyosin ATPase
activity. Excellent sensitivity but present in a subset of
myofibroblasts.128 129
< H-caldesmon: SMA binding protein. Only detectable
in myoepithelial cells of ducts but not found in
myofibroblasts.129 130
Cytokeratins
< Myoepithelial cells express cytokeratins (CK) characteristic of
basal layer of stratified epithelium: CK5, CK10, CK14 and
CK17.131 132
< CK5/6 in normal breast can be detected in both myoepithelial
and luminal epithelial cells.133
< The antibody 34b12 recognises CKs 1, 5, 10 and 14 but is not
specific for myoepithelial cells.134
Other markers
< S100: has low specificity since detectable in epithelial cells.135
< CD10 (Common Acute Lymphoblastic Leukaemia Antigen
(CALLA)): endopeptide expressed in myoepithelial cells.136
Antibodies now available that work on fixed tissue; high
sensitivity in normal breast.137
< P cadherin: cell adhesion molecule with high sensitivity for
myoepithelial cells in normal breast, no reactivity with
myofibroblasts.138
< P63-p53 homologue: differs from other markers in being
nuclear139 with high sensitivity for myoepithelial cells.140
< 14-3-3s: protein associated with apoptosis and cell cycle
control, present in myoepithelial cells in normal breast.141
< Maspin: serine protease inhibitor present in myoepithelial
cells142 with both cytoplasmic and nuclear reactivity.
Diagnostic areas
Radial scar versus tubular carcinoma
Highly sensitive and specific markers are required due to
myoepithelial cells in central parts of radial scars being attenuated,
plus the presence of myofibroblasts. The requirements
favour SMMHC and p63 as markers of choice. SMA and, to
a lesser extent, calponin will be present in myofibroblasts.
Papillary lesions
IHC can reduce the variability in reporting of core biopsies of
papillary lesions, particularly in relation to B3 and B4.143 Intraduct
papillomas have a complete layer of myoepithelial cells,
whether detected by SMMHC, calponin, p63 and CK5/6144 or
SMA, p63, CD10 and CK14.145 However, findings for intracystic
papillary carcinomas differ, with Collins et al144 failing to detect
any myoepithelial cells and Tse et al145 finding them to be
scattered and discontinuous. p63 had the highest sensitivity,
CK14 was also present in florid hyperplasia, SMA showed
stromal staining and CD10 epithelial and stromal staining.
Hyperplasia versus atypia versus DCIS
High molecular weight basal cytokeratins are of use particularly
in interpretation of core biopsies enabling a B2 rather than a B3
diagnosis. Myoepithelial cells form a useful internal positive
control. Hyperplasia of usual type and hyperplasia in papillomas
show reactivity for CK5/6133 146 147 and CK14146 whereas
atypical hyperplasia and DCIS epithelium do not.
Non-invasive versus invasive carcinoma
Myoepithelial cell markers can be of value in assessing whether or
not invasion is present, but myofibroblast reactivity, discontinuity
of staining of myoepithelial cells and staining of vascular smooth
muscle cells can cause problems in interpretation. Discontinuous
staining can occur with p63,140 148 but it has greater sensitivity
and specificity. SMMHC has been found to be more sensitive than
CD10 in assessing invasion149 but is in vascular smooth
muscle cells. Owing to the advantages and disadvantages, it is
better to use two myoepithelial markers that complement one
anotherdfor example, p63 and SMMHC or calponin.
Myoepithelial tumours
SMA, CK5/6, CK14, p63 and other markers are all suitable for
analysing possible (adeno) myoepithelial tumours, both benign
and malignant.150
Other lesions
Myoepithelial markers can aid differentiation of adenoid cystic
carcinoma from collagenous spherulosis and cribriform carcinoma.
Basal-like carcinomas
There is increasing interest in basal-like breast carcinomas, partly
due to the finding that BRCA1-related breast cancers can have
these features151 and to their poorer response to anthracycline
Key points and recommendations
Despite the extensive literature, there is still a lot of debate about
the importance and significance of micrometastases and isolated
tumour cells (ITCs), particularly with increasing use of sentinel
node biopsy. This impacts on factors such as the routine
pathological handling of sentinel nodes.
< If a micrometastasis is identified in a single H&E section,
levels should be cut to check whether it remains a micrometastasis
or becomes a macrometastasis (pN1mi to pN1).
< Sentinel lymph nodes should be sliced at 1e2 mm with all pieces
embedded to ensure a full face H&E section. This is the minimum
requirement. Step sectioning at 200e250 mm can be undertaken
but is not mandatory. It would be appropriate for centres
undertaking detailed clinical studies of sentinel lymph nodes.
< There is no good evidence for the routine use of
immunohistochemistry in evaluating sentinel lymph nodes; it
could be of value for centres undertaking detailed clinical
studies of sentinel lymph nodes.
< DefinitionsdAJCC/UICC amended definitions to be followed;
discrimination between micrometastases and ITCs can be
aided by using criteria from the European Working Group and
Turner studies.
< Since there are variations in the incidence of non-sentinel
node metastases in the presence of sentinel node micrometastasis,
axillary surgery/radiotherapy is considered appropriate
but is not indicated for ITCs.
< There is no strong evidence for an effect of micrometastases
on survival.
Further data are required in several areas to assess the significance
and importance of micrometastases and isolated tumour cells.
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chemotherapy.152 There is no consensus as to the definition of
basal-like, which probably reflects the view that they are
a heterogeneous group of cancers. Nielsen et al153 consider them to
express CK5/6, HER-1 (EGFR) and/or c-kit and lack ER and HER2.
Others have used CK14154 or P-cadherin155 as a basal marker to
identify these tumours. Rakha et al156 have proposed that basallike
carcinomas can be defined based on the expression of basal
cytokeratins (CK5/6 and CK14) irrespective of other markers.
OESTROGEN RECEPTOR ASSESSMENT IN DUCTAL CARCINOMA
IN SITU (DCIS)
The response of invasive breast cancer to endocrine therapy is
well recognised as being related to the hormone receptor status
of the tumour.157 It is therefore logical to investigate the role of
hormone receptors in determining the role of endocrine therapy
in the management of DCIS. However, to date, there remain
issues with regard to the latter and with the assessment of
hormone receptors.
Evidence from clinical trials
The value of tamoxifen in the management of DCIS has been
reported in two randomised studies:
1. The NSABP B-24 trial of the use of tamoxifen and
radiotherapy in DCIS showed a benefit from endocrine
therapy, primarily due to a reduction of ipsilateral recurrent
invasive carcinoma.157 158 The 7-year risk of local recurrence
in the treated breast after lumpectomy plus radiation was
reduced from 11.1% without tamoxifen to 7.7% with
tamoxifen (p¼0.02). The risk of all breast cancer events
(ipsilateral plus contralateral) was reduced from 16.9% to
10.0% (p¼0.0003). Allred and colleagues retrospectively
reviewed 628 cases from this trial and demonstrated that
the benefit was confined to those patients whose tumours
were ER positive; this was defined as 10% or more cells
staining.159 However, it is not clear whether there was
a difference in ipsilateral and/or contralateral recurrence with
regard to ER status of the primary disease process as the data
are available in abstract form only. It is also not clear how the
figure of 10% was reached and, in particular, whether
modelling was carried out to determine a cut-off value or
range that best correlated with therapeutic benefit. The
review included a mixture of both locally reported ER
and central assays and concern was raised about possible
false negative results from laboratories using diverse nonstandardised
assays. With the exception of the abstract
referred to above, the study has not been published.
2. The UK/ANZ (UKCCCR) Trial160 comparing radiotherapy
and tamoxifen in the treatment of DCIS showed after
53 months of follow-up a non-significant reduction in all
breast events with the addition of tamoxifen but a RR
reduction of 22%. It should be noted that the follow-up
period in the UK/ANZ trial at the time of reporting was
shorter than NSABP B-24 (4.4 vs 6.9 years) and receptor
status of the DCIS was not measured prospectively in this
trial. In addition, a high proportion of cases were of high
cytonuclear grade; a relatively high proportion are therefore
likely to be ER negative which will have influenced the effect
of hormone treatment in this series (S E Pinder, personal
communication).
A further study, the NSABP-P1 trial of tamoxifen for the
prevention of breast cancer, studied 13 000 at-risk women.161
This cohort did not include patients with DCIS but illustrates
the potential benefit of endocrine therapy in the prevention of
breast cancer events. Invasive and non-invasive carcinomas were
reduced by 50% at 69 months follow-up. There was a threefold
increase in thromboembolic events, a marginal increase in
cataracts and a non-significant increase in strokes.
Current guidance and options
A cut-off point for positive versus negative for ER in DCIS was
set at <5 an="an" as="as" cells="cells" clinical="clinical" criterion="criterion" entry="entry" for="for" p="p" staining="staining" two="two" uk="uk">trials of endocrine therapy in DCIS (IBIS II and DCIS II, the
latter discontinued). The UK breast screening guidelines162
recommend the use of <5 and="and" cells="cells" dcis="dcis" for="for" p="p" staining="staining" the="the" use="use">of the Allred score for invasive cancers. A cut-off of Allred score 3
has been used in a large study of pure DCIS examining the
distribution of various different phenotypes162 and is the same
as that applied to invasive breast carcinoma.157 162 It would be
illogical to adopt a different scoring system from those already
in use for invasive disease unless sound evidence to the contrary
emerged. Furthermore, there is strong evidence that the ER
status of invasive breast cancer parallels that of associated DCIS
in individual cases.163 Individual practitioners benefit from
familiarity with a particular scoring technique and clinical
colleagues require consistency in the approach to reporting. The
three scoring methods currently in use worldwide are: (1)
a simple percentage of cells staining without reference to
intensity; (2) the histochemical ‘H’ score which is the sum of the
percentage of cells with three levels of staining, giving a range of
0e300164; and (3) Allred scoring (replacing previous ‘Quick
Score’) which is the sum of an intensity score of 1e3 and the
percentage of cells staining banded in a non-linear fashion using
a score of 1e5 giving a final score between 2 and 8.165
Allred scoring and the histochemical score provide similar
information about receptor status as both include an assessment
of intensity as well as percentage of cell nuclei staining. Simple
percentage scoring gives no information about staining intensity
although low proportion scores tend to go hand in hand with
low intensity scoring with ER scoring, as opposed to PR
immunoreactivity.
There is no evidence base to support a preference for
a particular scoring technique. However, there is evidence for
assessment of proportion and intensity staining in invasive
breast cancer and, as such evaluation is routine practice, it would
be logical to mirror this practice in the reporting of DCIS.
Evidence from the Sloane Project,166 a UK audit of screendetected
DCIS and atypical hyperplasias of the breast, points to
Recommendations for a diagnostic panel
< It is important not to rely on just one marker.
< Smooth muscle myosin heavy chain (SMMHC) or calponin are
sensitive and specific cytoplasmic myoepithelial markers.
Smooth muscle actin can be used but care has to be taken in
interpretation in the presence of myofibroblasts.
< P63 is a sensitive and specific nuclear myoepithelial marker
but staining can be discontinuous, so use of a cytoplasmic
myoepithelial marker such as SMMHC or calponin as well will
aid interpretation.
< When trying to identify the presence/absence of myoepithelial
cells, use p63 and SMMHC/calponin.
< CK5/6 is of value in several diagnostic situations such as
analysis of hyperplasias or basal-like breast cancers.
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considerable confusion in this area among pathologists in their
reporting practice of ER status in DCIS. A wide variation is seen
between and within laboratories of the scoring method used and
also of the cut-off point for positive versus negative results. In
this audit, 40% of reporting laboratories used one method and
the same cut-off criterion throughout, 19% used one method but
different cut-off criteria for different cases, 15% of laboratories
used two methods for different cases with equivalent cut-off
points for each method while 25% of laboratories used two
methods and non-equivalent cut-off points from case to case.
Because there is such uncertainty about what cut-off is
therapeutically relevant (if any) in the pharmacological
management of DCIS and possibly as a more general prognostic
marker for this disease process, it would be sensible to record the
percentage of cells staining and the average intensity in the duct
profiles available and correlate this information with clinical
outcomes.
Patterns of ER expression in DCIS
From the data gathered by the Sloane Project, intermediate and
low-grade DCIS are almost invariably ER positive whereas
high-grade DCIS is positive in 69% of cases (table 2).
Baqai and Shousha reviewed 60 cases of DCIS, 56 pure and
four with associated microinvasion. DCIS was assessed in terms
of grade, architecture and, among other things, ER positivity
was defined as disease with >10% of cells showing dark brown
nuclear staining (Allred score >4, Histoscore >20). The grade
distribution seen was 52% high, 38% intermediate and 10% low,
which is very similar to the distribution among the Sloane
Project cases.168 There was a strong association between ER
negativity and high nuclear grade. The number of cases in this
study was small and the cut-off point was set relatively high. It
is a pity that the opportunity to model different cut-off points
against grade was not taken.
Ottesen et al169 showed in a series of 133 cases of DCIS that
one-third displayed 5% or less staining for ER, the overwhelming
majority of which were of large nuclear size. In this series,
perhaps unusually, most cases were either strongly positive or
negative.
Basal phenotype DCIS, seen in approximately 6% of
high-grade lesions, is commonly negative for ER, PR and
Her2.162 170 171
Future directions
It is likely that the IBIS II trial will give invaluable information
about the validity of setting a positive/negative cut-off point at
5% or 10% for ER. Obviously there will be limited information
about the relevance of staining intensity unless Allred scores are
used and these are not obligatory. The Sloane Project, given its
long-term goals of prolonged follow-up of DCIS patients, will
also provide information about a range of cut-off points because
of the variability that has already been demonstrated in the first
cohort of patients reviewed.167 Because data are not available to
give guidance on the clinical relevance of different proportion
and intensity scores, it is recommended as a minimum to record
both when reporting the hormone receptor status of DCIS. This
will enable Histoscores and/or Allred scores to be derived
without loss of the original scoring information.
There remains considerable scope for modelling ER cut-off
points in DCIS against clinical outcomes in large cohorts of
patients but, until such time as that is possible, it seems
reasonable to apply the limited evidence available at the present
time and use the currently accepted cut-off points to guide the
endocrine management of patients with DCIS as for reporting
ER status in invasive breast cancer.162
Acknowledgements The authors acknowledge the members of the UK National
Coordinating Committee for Breast Pathology.
Contributors These are working documents aimed to established early guidance on
emerging areas of diagnostic breast pathology.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.
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DCIS, ductal carcinoma in situ; ER, oestrogen receptor.
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< Metastatic tumour clusters in lymph nodes <0 .2=".2" are="are" mm="mm" p="p">designated isolated tumour cells. Discontinuous clusters
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J Clin Pathol 2012;65:771–785. doi:10.1136/jclinpath-2012-200733 785
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J Clin Pathol 2012 65: 771-785 originally published online July 19, 2012
Rosemary A Walker, Andy Hanby, Sarah E Pinder, et al.
pathology
Current issues in diagnostic breast
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