• Users Online: 261
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 34  |  Issue : 2  |  Page : 130-139

Changes of biomarkers expression between preoperative biopsy and after definitive surgical treatment in patients with invasive breast cancer who receive neoadjuvant chemotherapy


1 Department of General Surgery, Faculty of Medicine, Benha University, Benha, Egypt
2 Department of Pathology, Faculty of Medicine, Benha University, Benha, Egypt

Date of Submission05-Mar-2017
Date of Acceptance10-Apr-2017
Date of Web Publication20-Nov-2017

Correspondence Address:
Ahmed M.F Salama
Department of General Surgery, Faculty of Medicine, Benha University, Benha, 13511
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bmfj.bmfj_41_17

Rights and Permissions
  Abstract 


Background Neoadjuvant systemic therapy has become a valuable strategy in the multidisciplinary treatment approach to breast cancer. There are conflicting results regarding the effect of neoadjuvant chemotherapy (NAC) on estrogen receptor, progesterone receptor, and human epidermal growth factor 2 (Her2) status in breast cancer.
Aim The aim of this study was to shed some light on the effect of NAC on the biomarkers of breast cancer cells in patients with invasive cancer breast.
Patients and methods A total of 22 female patients with breast mass that proved to be malignant by tru-cut biopsy underwent HR, Her2, and Ki67 assessments following administration of NAC and excision of the tumors, which were sent for histopathological assessment and assessment of the aforementioned markers. Changes were analyzed according to the type of the tumor, the grade, the hormone receptor status, and Her2 status of the tumor. These patients were managed in the General Surgery and Pathology Department, Faculty of Medicine, Benha University Hospital, during the period from January 2015 to June 2016.
Results This study show that tumor cells that are hormone receptor negative and those that are Her2 positive are more sensitive to NAC with an obvious effect on proliferation index rate and higher rate of achieving complete pathological response. Infiltrating lobular carcinoma of the breast is associated with poorer response to NAC in comparison with duct carcinoma. The higher the grade of the tumor, the poorer the response to NAC.
Conclusion The study shows that the breast cancer cells that are hormone receptors negative, Her2 positive, duct carcinoma, and lower grade tumors are more responsive to NAC.

Keywords: breast cancer, estrogen receptor, human epidermal growth factor 2, neoadjuvant chemotherapy


How to cite this article:
Ezzat AS, Soueni HK, Agena HA, Nowar AM, Salama AM. Changes of biomarkers expression between preoperative biopsy and after definitive surgical treatment in patients with invasive breast cancer who receive neoadjuvant chemotherapy. Benha Med J 2017;34:130-9

How to cite this URL:
Ezzat AS, Soueni HK, Agena HA, Nowar AM, Salama AM. Changes of biomarkers expression between preoperative biopsy and after definitive surgical treatment in patients with invasive breast cancer who receive neoadjuvant chemotherapy. Benha Med J [serial online] 2017 [cited 2018 Jun 20];34:130-9. Available from: http://www.bmfj.eg.net/text.asp?2017/34/2/130/218832




  Introduction Top


Breast cancer is one of the most common malignant tumors in the world. Morphologically and biologically, breast cancer is a heterogeneous disease family, comprising a number of subtypes [1]. Neoadjuvant chemotherapy (NAC) has become a valuable strategy in the multidisciplinary treatment approach to breast cancer as it offers several advantages of earlier exposure of these micrometastases to chemotherapeutic agents, observed response to chemotherapy in the primary breast disease, and regression of tumor size, which can allow for a more conservative surgical procedure [2].

Nishimura et al. [3] stated that the effect of NAC on breast cancer immunohistochemical markers remains controversial. In this regard, Lee et al. [4] have reported changes in estrogen receptor (ER) and progesterone receptor (PR) expressions in 61% of patients undergoing NAC. However, Arens et al. [5] did not find any significant effect of NAC on ER, PR, and human epidermal growth factor 2 (Her2) expressions. Given these controversial findings, the current study aims to investigate the potential changes in ER, PR, Her2, and Ki67 expressions before and after NAC.


  Patients and methods Top


The study included 22 female patients with breast mass that proved to be malignant by tru-cut biopsy. These patients were managed in Department of General Surgery and Early Cancer Detection Unit, Pathology Department, Faculty of Medicine, Benha University Hospital, during the period from January 2015 to June 2016. The study was approved by the institutional Research Ethical Committee and a written informed consent was obtained from all participates.

Patients with carcinoma in situ or breast sarcomas were excluded from the study.

Tru-cut biopsy

All patients underwent tru-cut biopsy using 16-G automated tru-cut needle and manual localization of the mass. The biopsies were sent for histopathological assessment and immunohistochemical study (estrogen, progesterone, and Her2 receptors) and Ki67 assessment.

Neoadjuvant chemotherapy

All cases received three cycles of NAC repeated every 21 days in the form of the following:
  1. 5-Fluorouracil: 500 mg/m2.
  2. Epirubicin: 100 mg/m2.
  3. Cyclophosphamide: 500 mg/m2.


Patients were followed up for response monitoring after the first cycle of chemotherapy and after the end of the three cycles. This was done by tumor marker analysis (cancer antigen 15-3), mammography, and breast ultrasound ([Figure 1]).
Figure 1 Comparison between unilateral breast mammography before and after neoadjuvant chemotherapy: (a) craniocaudal view and (b) mediolateral view.

Click here to view


Good response was determined by lowering in cancer antigen 15-3 level and regression of the tumor size.

Surgical resection of the tumor

Timing of the surgery

Surgery was performed 4–6 weeks after the last NAC cycle after assessment of the residual tumor through clinical examination, mammography, and breast ultrasound.

Type of the operation

The type of operation depends on the extent of disease at presentation, patient choice, and clinical response to NAC (either breast-conserving surgery or modified radical mastectomy).

Extent of resection is determined by the original tumor size before NAC without taking into the consideration the residual size of the tumor after NAC. The specimens were sent for histopathological and immunohistochemical assessments.

Evaluation of the results

Biological markers (estrogen, progesterone, and Her2 receptor) and Ki67 level of the tumor cells are compared before (in the tru-cut biopsy) and after (in the surgically removed breast specimen) the NAC administration using immunohistochemical methods according to manufacturer’s instructions as shown in [Table 1]:
Table 1 The immunohistochemical analysis method used in the study

Click here to view


Statistical analysis

Statistical analysis was conducted using STATA/SE 11.2 for Windows (STATA Corporation, College Station, Texas, USA). The collected data were summarized in terms of mean±SD and range for quantitative data and frequency and percentage for qualitative data. Comparisons between the different study groups were carried out using the test of proportion (Z-test) to compare two proportions. The Fisher exact test was used to compare more than two proportions. Comparisons between paired proportions were carried out using the exact McNemar test.

The corresponding P values were obtained. A P value less than 0.05 was considered statistically significant, a P value less than 0.001 was considered statistically highly significant, and a P value greater than 0.05 was considered statistically nonsignificant.


  Results Top


Descriptive statistics

The demographic data of the study group are shown in [Table 2]. Of the studied cases, 22 patients were diagnosed as having invasive cancer breast radiologically and pathologically. Histologically, six (27.27%) patients present with invasive lobular carcinoma (ILC) and 16 (72.73%) patients had IDC. Only two (9.09% of cases) patients had grade III tumor, whereas the other 20 (90.91%) patients had grade II tumor. A total of eight (36.36%) patients had stage IIB cancer breast, 10 (45.45%) patients had stage IIIA, and four (18.18%) patients presented with stage IIIC ([Figure 2]).
Table 2 Descriptive statistics of the studied cases

Click here to view
Figure 2 Descriptive statistics of the cases.

Click here to view


Analysis of the changes in breast cancer receptors according to tumor type

Estrogen receptors

A total of 10 (62.5%) cases showed changes from ER positive to positive in IDC compared with only one (16.7%) case in ILC. No cases remained negative after NAC. In addition, two (33%) cases changed from negative to positive in ILC, compared with no cases in IDC. This was statistically significant. Moreover, five (31%) cases changed from positive to negative in IDC compared with three (50%) cases in patients with ILC; however, this was statistically insignificant ([Table 3] and [Figure 3]).
Table 3 Changes in estrogen receptor status according to tumor type

Click here to view
Figure 3 Effect of neoadjuvant chemotherapy on estrogen receptor (ER) expression, which shows downregulation from +3 (a) to +1 (b).

Click here to view


Progesterone receptors

A total of five (31.25%) cases show changes from PR positive to positive in IDC compared with no cases in ILC. One (6%) case remains negative after NAC in patients with IDC compared with two (33%) cases in patients with ILC. Overall, four (25%) cases changed from negative to positive in patients with IDC compared with two (33%) cases in ILC. Moreover, five (31%) cases changed from positive to negative in IDC compared with two (33%) cases in patients with ILC ([Table 4] and [Figure 4]).
Table 4 Changes in progesterone receptor status according to tumor type

Click here to view
Figure 4 Effect of neoadjuvant chemotherapy on progesterone receptor (PR) receptor expression, which shows a change from +3 (a) to negative (b).

Click here to view


Human epidermal growth factor 2 receptor

A total of three (18.75%) cases showed change from Her2 positive to positive in IDC compared with one (16.7%) case in ILC. In addition, five (31%) cases remained negative after NAC in patients with IDC compared with two (33%) cases in patients with ILC, and three (19%) cases changed from negative to positive in patients with IDC compared with three (50%) cases in those with ILC. Moreover, four (25%) cases changed from positive to negative in IDC compared with no cases in patients with ILC; however, it did not reach statistical significant value ([Table 5] and [Figure 5]).
Table 5 Changes in human epidermal growth factor 2 receptor status according to tumor type

Click here to view
Figure 5 Effect of neoadjuvant chemotherapy on human epidermal growth factor 2 (Her2) receptor expression, which shows down regulation from +3 (a) to +2 (b).

Click here to view


Ki67 level

Current study shows remarkable change in Ki67 level from high to low in nine (56%) cases of patients with IDC compared with two (33%) cases in patients with ILC; however, this was statistically insignificant. Moreover, five (31%) cases show change in Ki67 level from high to moderate in patients with IDC compared with three (50%) cases in patients with ILC, and one case each remains has high Ki67 level after NAC in IDC cases (6%) and in ILC cases (17%) ([Table 6] and [Figure 6])
Table 6 Changes in Ki67 level according to tumor type

Click here to view
Figure 6 Effect of neoadjuvant chemotherapy on Ki67 level which shows downregulation from high (a) to low (b) level.

Click here to view


There was only one case that shows pathological complete response (pCR) after NAC which was of IDC-type breast cancer.

Analysis of the changes in breast cancer receptors according to tumor grade

Estrogen receptors

A total of nine (45%) cases showed changes from ER positive to positive in grade II compared with only two (50%) case in grade III tumors, which was statistically significant at the different degrees of changes. No cases remained negative after NAC. Moreover, two (10%) cases changed from negative to positive in grade II tumors compared with no cases in grade III tumors, and eight (40%) cases changed from positive to negative in grade II tumors compared with no cases in grade III tumors ([Table 7] and [Figure 7]).
Table 7 Changes in estrogen receptor status according to tumor grade

Click here to view
Figure 7 Changes in estrogen receptor (ER) status according to tumor grade.

Click here to view


Progesterone receptors

A total of five (25%) cases showed changes from PR positive to positive in grade II tumors compared with no cases in grade III tumors, and three (15%) cases remain negative after NAC in grade II tumors compared with no cases in grade III tumors. Overall, four (20%) cases changed from negative to positive in grade II tumors compared with two (100%) cases in grade III tumors, which shows a statistical significance (0.01). In addition, seven (35%) cases changed from positive to negative in grade II tumors compared with no cases in grade III tumors ([Table 8] and [Figure 8]).
Table 8 Changes in progesterone receptor status according to tumor grade

Click here to view
Figure 8 Changes in progesterone receptor (PR) status according to tumor grade.

Click here to view


Human epidermal growth factor 2 receptor

A total of three (15%) cases showed changes from Her2 positive to positive in grade II tumors compared with one (50%) case in grade III tumors [one (5%) case remained +2 in grade II tumors compared with one case in grade III tumors; this was statistically significant (0.03)]. Overall, seven (35%) cases remained negative after NAC in grade II tumors compared with no cases in grade III tumors, and five (25%) cases changed from negative to positive in grade II tumors compared with one (50%) case in grade III tumors. In addition, four (20%) cases changed from positive to negative in grade II tumors compared with no cases in grade III tumors ([Table 9] and [Figure 9]).
Table 9 Changes in human epidermal growth factor 2 receptor status according to tumor grade

Click here to view
Figure 9 Changes in human epidermal growth factor 2 (Her2) receptor status according to tumor grade.

Click here to view


Ki67 level

Current study shows remarkable change in Ki67 level from high to low in 11 (55%) cases in grade II tumors compared with no cases in grade III tumors; however, this was statistically insignificant. A total of six (30%) cases showed change in Ki67 level from high to moderate in grade II tumors compared with two (100%) cases in grade III tumors, and two (10%) cases remained showing a high Ki67 level after NAC in grade II tumors compared with no cases in grade III tumors ([Table 10] and [Figure 10]).
Table 10 Changes in Ki67 level according to tumor grade

Click here to view
Figure 10 Changes in Ki67 level according to tumor grade.

Click here to view


There was only one case that showed pCR after NAC which was of grade II tumor.

Analysis of the changes in breast cancer receptors according to tumor stage

Estrogen receptors

In stage IIB, no cases showed changes from ER positive to positive compared with seven (70%) cases in stage IIIA and four (100%) cases in stage IIIC, which was statistically significant at the different degrees of changes. No cases remained negative after NAC. A total of two (25%) cases changed from being negative to positive in stage IIB compared with no cases in stage IIIA and IIIC, and five (62.5%) cases changed from positive to negative in stage IB compared with three (30%) cases in stage IIIA, and no cases in stage IIIC ([Table 11]).
Table 11 Changes in estrogen receptor status according to tumor stage

Click here to view


Progesterone receptor

In stages IIB and IIIC, no cases showed changes from ER positive to positive compared with five (50%) cases in stage IIIA. No cases remained negative after NAC in stages IIB and IIIC compared with three (30%) cases in stage IIIA. Two (25%) cases were changed from negative to positive in stage IIB compared with no cases in stage IIIA and four (100%) cases in stage IIIC. This was statistically significant (0.001). A total of five (62.5%) cases changed from positive to negative in stage IIB compared with two (20%) cases in patients with stage IIIA and no cases in stage IIIC ([Table 12]).
Table 12 Changes in progesterone receptor status according to tumor stage

Click here to view


Human epidermal growth factor 2 receptors

In stage IIB, no cases shows changes from ER positive to positive compared with two (20%) cases in stage IIIA and two (50%) cases in stage IIIC [no cases remain +2 in stage IIB and stage IIIA compared with two (50%) cases in stage IIIC, which shows statistical significance (0.03)]. A total of four (50%) cases remained negative after NAC in stage IIB compared with three (30%) cases in stage IIIA, and no cases in stage IIIC. In addition, one (12.5%) case changed from negative to positive in stage IIB compared with three (30%) cases in stage IIIA and two (50%) cases in stage IIIC. Moreover, two (25%) cases change from positive to negative in stage IIB compared with two (20%) cases in patients with stage IIIA and no cases in stage IIIC ([Table 13]).
Table 13 Changes in human epidermal growth factor 2 receptor status according to tumor stage

Click here to view


Ki67 level

Current study shows remarkable change in Ki67 level from high to low in six (75%) cases in patients with stage IIB compared with five (50%) cases in patients with stage IIIA, and no cases in stage IIIC; however, this was statistically insignificant. One (12.5%) case showed change in Ki67 level from high to moderate in patients with stage IIB compared with three (30%) cases in patients with stage IIIA and four (100%) cases in those with stage IIIC, which shows statistical significance (0.01). No cases remain high Ki67 level after NAC in stages IIB and IIIC and in comparison with two (20%) cases in patients with stage IIIA ([Table 14]).
Table 14 Changes in Ki67 level according to tumor stage

Click here to view


There was only one (12.5%) case in stage IIB that shows pCR after NAC.


  Discussion Top


In the present study, it is found that tumor cells that are hormone receptor negative are more sensitive to chemotherapy (100% of cases change to low Ki67 level) than hormone receptor-positive tumors (52.6% of the cases). These results are in agreement with previous studies by Tan et al. [6], Caudle et al. [7], and Precht et al. [8], which showed that hormone receptor-positive tumor cells, known as insensitive tumor cells, are left behind as part of the residual disease after NAC or have a higher proliferation index (Ki67).

This study also shows that Her2-positive tumor cells are more sensitive to chemotherapy (71.8% of cases change to low Ki67 level) and also more likely to be eliminated by chemotherapy. This result was in agreement with Quddus et al. [9] and Wang et al. [10] which showed that Her2-positive tumors are more sensitive to chemotherapy with an obvious effect on proliferation index rate and higher rate of achieving pCR.

This study shows that the type of tumor affects the degree of changes in different breast cancer receptors. The study reveals that in IDC type, the ER-positive tumor mainly change the degree of positivity of the ER expression (62.5% of cases) and highly affect the proliferation rate, as 68.75% of cases showed decrease in Ki67 level in response to NAC. However, in ILC types, most cases show changes in receptors expression, including ER (33.3%), PR (66.6%), and Her2 (83.3%) expressions. However, the effect of NAC on proliferation index was only in 33.3% of cases. This result is comparable and in agreement with Martin et al. [11] which stated that ILC of the breast is associated with poorer response to NAC, when compared with IDC as regarding the pCR and breast-conserving surgery.

Our study reveals that the higher the grade of the tumor, the less the effect of the NAC on breast cancer receptors. The study shows that grade II tumors show variable changes in ER expression, whereas in grade III tumors, the change was only on the degree of positivity of ERs (100% of cases), which shows statistical significance (P=0.03). On PR expression, grade III tumors show changes from negative to positive (100% of cases), which was statistically significant in comparison with grade II tumors (20%) (P=0.01). Grade III tumors show no change in Her2 expression in 50% of cases, which was statistically significant in comparison with grade II tumors (5% of cases) (P=0.03). A minor effect on proliferation index was observed in grade III tumors (in 100% of the cases) in comparison with grade II tumors (40% of cases), which reflects the poorer response to NAC in high-grade cancer breast. This result is comparable and in agreement with a study by Caudle et al. [7] which also stated that high-tumor grade has been demonstrated to be a predictor of poor response to NAC and recurrence in patients with breast cancer.

The study reveals that the higher the stage of the disease, the poorer the response to NAC. In our study, stage IIB tumors show a higher rate of change in ER (100% of cases) and PR (100% of cases) expressions in response to NAC and lowering in the proliferation index of the tumor cells (in 100% of cases). Stage IIIA shows fewer changes in estrogen (30%) and progesterone (20%) expressions. The effect on proliferation index of tumor cells is equivocal between stages IIB and IIIC tumors (50% of cases show good response). In stage IIIC cancers, no cases show changes in ER expression (a poor response), and 100% of cases show less effect on proliferation index than other tumor stages. In contrast to our results, a study by Smith et al. [12] reported that stage of the disease is not a predictive factor for the tumor response to NAC. These discordant results may be attributed to the small number of cases in this study.


  Conclusion Top


The ER, PR, and Her2 status of patients with breast cancer may change following NAC. The study shows that the breast cancer cells which are hormone receptor negative and Her2 positive are more responsive to NAC. Duct carcinoma breast cancer is more responsive to NAC than lobular carcinoma. The higher the grade of the tumor the poorer the response to NAC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Stingl J, Caldas C. Molecular heterogeneity of breast carcinomas and the cancer stem cell hypothesis. Nat Rev Cancer 2007; 7:791–799.  Back to cited text no. 1
[PUBMED]    
2.
Kaufmann M, Hortobagyi GN, Goldhirsch A. Recommendations from an international expert panel on the use of neoadjuvant (primary) systemic treatment of operable breast cancer: an update. J Clin Oncol 2006; 24:1940–1949.  Back to cited text no. 2
    
3.
Nishimura R, Osako T, Okumura Y, Hayashi M, Arima N. Clinical significance of Ki-67 in neoadjuvant chemotherapy for primary breast cancer as a predictor for chemosensitivity and for prognosis. Breast Cancer 2010; 17:269–275.  Back to cited text no. 3
[PUBMED]    
4.
Lee SH, Chung MA, Quddus MR, Steinhoff MM, Cady B. The effect of neoadjuvant chemotherapy on estrogen and progesterone receptor expression and hormone receptor status in breast cancer. Am J Surg 2003; 186:348–350.  Back to cited text no. 4
    
5.
Arens N, Bleyl U, Hildenbrand R. HER2/neu, p53, Ki67, and hormone receptors do not change during neoadjuvant chemotherapy in breast cancer. Virchows Arch 2005; 446:489–496.  Back to cited text no. 5
[PUBMED]    
6.
Tan MC, Al Mushawah F, Gao F, Aft RL, Gillanders WE, Eberlein TJ. Predictors of complete pathological response after neoadjuvant systemic therapy for breast cancer. Am J Surg 2009; 198:520–525.  Back to cited text no. 6
    
7.
Caudle AS, Gonzalez-Angulo AM, Hunt KK, Liu P, Pusztai L, Symmans WF, Kuerer HM. Predictors of tumor progression during neoadjuvant chemotherapy in breast cancer. J Clin Oncol 2010; 28:1821–1828.  Back to cited text no. 7
    
8.
Precht LM, Lowe KA, Atwood M, Beatty JD. Neoadjuvant chemotherapy of breast cancer: tumor markers as predictors of pathologic response, recurrence, and survival. Breast J 2010; 16:362–368.  Back to cited text no. 8
[PUBMED]    
9.
Quddus RM, Sung JC, Zhang C, Pasqueriello T, Eklund M, Steinhoff MM. HER-2/neu expression in locally advanced breast carcinomas: pre- and post-neoadjuvant chemotherapy. Breast Cancer 2005; 12:294–298.  Back to cited text no. 9
[PUBMED]    
10.
Wang J, Buchholz TA, Middleton LP, Allred DC, Tucker SL, Kuerer HM et al. Assessment of histologic features and expression of biomarkers in predicting pathologic response to anthracycline-based neoadjuvant chemotherapy in patients with breast carcinoma. Cancer. 2010; 94:3107–3114.  Back to cited text no. 10
    
11.
Martin HL, Walsh G, Khabra K, Skinner T, Smith IE. Neoadjuvant chemotherapy in invasive lobular breast carcinoma: comparison of response, surgery and disease free survival with invasive ductal carcinoma. Cancer Res 2015;75. DOI: 10.1158/1538-7445.SABCS14-P3-11-05.  Back to cited text no. 11
    
12.
Smith IC, Heys SD, Hutcheon AW, Miller ID, Payne S, Gilbert FJ. Neoadjuvant chemotherapy in breast cancer: significantly enhanced response with docetaxel. J Clin Oncol 2010; 20:1456–1466.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed64    
    Printed1    
    Emailed0    
    PDF Downloaded14    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]