Discordance in hormone receptor status in breast cancer during tumour progression Eva Karlsson (1,2) Linda Lindström (1) Ulla Wilking (1) Lambert Skoog (3) Ulla Johansson (4) Jonas Bergh (1,5) 1. Department of Oncology and Pathology Cancer Center Karolinska Karolinska Institutet,Stockholm, Sweden, 2. Department of Oncology Karlstad Hospital,Sweden 3. Department of Pathology/Cytology Karolinska University Hospital 4. Center of Oncology Stockholm 5. Dept of Medical Oncology,The Christie,Manchester University/Paterson Institute, UK

Discordance in hormone receptor status in breast cancer during tumour progression Background Today therapy management of breast cancer relapse is almost always based of primary tumour characteristics such as ER / PR and HER2 status, sites of relapse and relapse free survival time Diagnosis of breast cancer relapse is therefore based on a combination of clinical and radiological examinations In rare instances image diagnosis of relapse may actually represent a benign lesion or a new primary cancer or metastases from another malignancy

Discordance in hormone receptor status in breast cancer during tumour progression Background Lack of stability in hormone receptors between primary breast cancer and corresponding relapse have been reported Despite repeated observations, management of metastatic breast cancer patients has essentially been unchanged and based on primary tumour characteristics Estrogen receptor status in primary breast cancers compared with the corresponding relapses Publication / AbstractPatientsDiscordant Patients AuthorNumberPercent Liedtke et al, 2009 Ann Oncol22818,4 Broom et al, 2009 Anticancer Res6217,7 Simmons et al, 2009 Ann Oncol2540 Amir et al, 2008 Clin Oncol955,6 Guarneri et al, 2008 The Oncologist7522,7 Wu et al, 2008 Clin Cancer Res1020 Lower et al, 2005 Breast Res Treat20030 Wang et al, 2004 Ai Zheng6535,4 Nedergaard et al, 1995 APMIS10120,8 Kamby et al, 1989 Br J Cancer6237,1

Discordance in hormone receptor status in breast cancer during tumour progression Aims Determine if hormone receptors (ER / PR) change between primary breast cancer and recurrence Material and method 1095 breast cancer patients in Stockholm who relapsed during All available information on these individuals were requested from the Center of Oncology Stockholm Primary cancers and corresponding relapses were retrospectively compared for hormonal receptor status

Discordance in hormone receptor status in breast cancer during tumour progression Material and methods Hormone receptor data were manually collected from the original pathology reports We gave first priority to immunohistochemistry (IHC) for ER/PR, if not available we used immunocytochemistry (ICC) from the cytology aspirates, which routinely is performed and if not available we used biochemical receptor determination Aspiration cytology was originally invented and described at Karolinska Hospital some 50 years ago. The technique requires considerable manual skills and is at Karolinska only practiced by a few very experienced cytopathologist performing the tumour aspirations and they have developed the techniques for ICC for ER, initially in parallel with the biochemical receptor determinations. This retrospective study was approved by the Ethical committee at the Karolinska Institutet

Discordance in hormone receptor status in breast cancer during tumour progression Results In 486 patients ER information were available from both primary and one or more recurrent sites resulting in 679 patients pairs ER changed in 27% from positive in primary tumour to negative in relapse and 8% changed from negative to positive In 456 patients PR information were available from both primary and one or more recurrent sites resulting in 630 patients pairs PR status changed in 38% from positive in primary tumour to negative in relapse and 5% changed from negative to positive

Overall breast cancer survival from the time of primary tumour diagnosis to death or censoring contrasting intra-individual ER status in primary tumour and relapse (both local and systemic relapses included)

Overall breast cancer survival from the time of relapse diagnosis to death or censoring contrasting intra-individual ER status in primary tumour and relapse (both local and systemic relapses included)

Risk of death depending on intra-individual ER status in primary tumour and relapse

Discordance in hormone receptor status in breast cancer during tumour progression Methodological issues Our results are based on both biochemical receptor determinations and IHC/ICC with very similar data for concordant and discordant use of the methods, respectively The concordance between the biochemical and IHC/ ICC methods are high (ER 82% to 93%) New data at Departement of Pathology/Cytology Karolinska from 683 breast cancer patients with ER status from both IHC and biochemical methodes, and the concordance between them was high 88% ( manuscript Mahmoud R. Khoshnoud et al) The pathology laboratory at Karolinska University Hospital has continuously participated in quality assurance programmes for receptor analyses, both during the era of biochemical determinations and the present IHC/ICC techniques and all these different techniques were run parallel for years The usage of the different methods will therefore likely not explain our findings

Discordance in hormone receptor status in breast cancer during tumour progression Potential shortcomings This study is retrospective with retrospectively collected information on hormonal receptor status Hormone receptor data were manually collected from the original pathology reports We gave first priority to immunohistochemistry (IHC ) for ER/PR, if not available we used immunocytochemistry (ICC) from the cytology aspirates, which routinely is performed and if not available we used biochemical receptor determination On one hand as for all immunohistochemical / immunocytochemical techniques, they may be falsely negative and positive on the other hand not systematically in one direction

Discordance in hormone receptor status in breast cancer during tumour progression Conclusions Biopsy of a suspected ”metastatic” breast cancer lesion will improve the diagnostic precision, for single patients offer alternative/better therapies and even occasionally exclude recurrent breast cancer Nearly every third patient with breast cancer change hormone receptor status during tumour progression Increased risk of dying were seen in patients loosing ER during tumour progression compared with stable ER positive patients Therapy management of metastatic disease is suboptimal when only based on primary tumour characteristics Our data together with multiple small and retrospective data even from a prospective study (Simmons et al 2009 Ann Oncol) underlines the needs for practice change

Discordance in hormone receptor status in breast cancer during tumour progression “Put simply, failure to biopsy recurrent or metastatic breast cancer carries a significant risk that our management is inadequately informed and may be inappropriate” (Sharma et al Nature Reviews Clinical Oncology 2010)

Acknowledgement All the patients The clinical colleagues at Karolinska who had high ambitions in aiming at securing the “correct” diagnosis of the breast cancer patients at time of clinically and radiologically (suspected) relapse Anders Höög (Karolinska), Anna-Lena Borg (CCK), Torsten Hägerström (CCK) Mikael Bergenheim (Karlstad Hospital) Sten-Åke Lindahl (Karlstad Hospital) Bo Nordenskjöld (Linköping University Hospital) Elisabet Lidbrink (Karolinska University Hospital) The Swedish Breast Cancer Association (BRO), FOU Värmland Jonas Bergh’s research group is supported by grants from the Swedish Cancer Society, the Stockholm Cancer Society, the King Gustav V Jubilee Fund, the Swedish Research Council, the Stockholm City Council, Karolinska Institutet and Stockholm County Council Research Strategy Committee, The Swedish Breast Cancer Association (BRO), the Karolinska Institutet Research Funds, Manchester University, Christie Hospital & Paterson Institute and Märit and Hans Rausing´s Initiative against Breast Cancer

Discordance in hormone receptor status in breast cancer during tumour progression The reported switch of hormonal receptors may partly represent tumour progression and selection influence from the microenvironment intratumour heterogeneity influence by given therapy methodological shortcomings regarding receptor determination

Discordance in hormone receptor status in breast cancer during tumour progression Relapse sites stratified on relapse ER status

Discordance in hormone receptor status in breast cancer during tumour progression ER status in tumour relapse