David Peston

Preoperative gefitinib versus gefitinib and anastrozole in postmenopausal patients with oestrogen-receptor positive and epidermal-growth-factor-receptor-positive primary breast cancer: a double-blind placebo-controlled phase II randomised trial.

BACKGROUND Some oestrogen-receptor (ER) positive breast cancers express epidermal growth factor receptor (EGFR), but whether inhibition of EGFR can suppress proliferation of breast cancer cells and ER function is not known. METHODS In a double-blind, placebo-controlled randomised trial of 56 postmenopausal patients with ER-positive and EGFR-positive primary breast cancer, 27 women were randomly assigned to the tyrosine-kinase inhibitor of EGFR gefitinib (250 mg given orally once a day) and the aromatase inhibitor anastrozole (1 mg given orally once a day), and 29 women to gefitinib (250 mg given orally once a day) and placebo of identical appearance to anastrozole given orally once a day, all given for 4-6 weeks before surgery. Primary outcome was inhibition of tumour-cell proliferation, as measured by Ki67 antigen labelling index. Secondary outcomes were reduction in EGFR phosphorylation at Tyr 845, reduction in ER phosphorylation at Ser 118, tumour size, and toxic effects. Analyses were by intention to treat. FINDINGS Patients assigned gefitinib and anastrozole had a greater reduction from pretreatment values in proliferation-related Ki67 labelling index than did those assigned gefitinib alone (mean % reduction 98.0 [95% CI 96.1-98.9] vs 92.4 [85.1-96.1]; difference between groups 5.6% [5.1-6.0], p=0.0054). Tumour size was reduced by 30-99% (partial response) in 14 of 28 patients assigned gefitinib and [corrected]in 12 of 22 assigned gefitinib, as assessed by ultrasonography. Reduction in phosphorylation of ER at Ser 118 was similar for both groups. Treatment was well tolerated and much the same for both groups. INTERPRETATION Single-agent gefitinib and gefitinib combined with anastrozole are well-tolerated and effective treatments for reducing the size of breast tumours and levels of ER phosphorylation when given as neoadjuvant therapy.

Phosphorylation of Estrogen Receptor-α at Ser167 Is Indicative of Longer Disease-Free and Overall Survival in Breast Cancer Patients

Purpose: Ser167 was first identified as a major phosphorylation site of the estrogen receptor -α (ER) positive in the MCF7 breast cancer cell line. Subsequent studies have shown that Ser167 phosphorylation is important in the regulation of ER activity and have identified p90RSK and AKT as protein kinases that phosphorylate Ser167. The purpose of this study was to determine the importance of Ser167 phosphorylation in breast cancer progression. Experimental Design: Immunohistochemical staining of primary breast cancer biopsies (n = 290) was carried out using antibodies specific for ER phosphorylated at Ser167 and for phosphorylated p44/p42 mitogen-activated protein kinase (MAPK), phosphorylated p90RSK, and phosphorylated AKT. Results: In ER-positive breast cancer patients, Ser167 phosphorylation was associated with low tumor grade (P = 0.011), lymph node negativity (P = 0.034), and relapse-free (P = 0.006) and overall (P = 0.023) survival. Further, Ser167 phosphorylation was strongly associated with phosphorylated p90RSK (P < 0.001), previously shown to phosphorylate Ser167 in vitro, as well as being associated with phosphorylated MAPK (P < 0.0005). The activities of both kinases also seemed to be indicative of better prognosis. There was, however, no association between HER2 positivity and Ser167 phosphorylation nor were the activities of MAPK or p90RSK associated with HER2 status, suggesting that other cell surface receptors may be important in regulating these activities in breast cancer. Conclusions: These findings show that phosphorylation at Ser167 of ER predicts for likelihood of response of ER-positive breast cancer patients to endocrine therapies.

CD10 immunostaining of bile canaliculi in liver biopsies: change of staining pattern with the development of cirrhosis

Aims : This study was prompted by published observations concerning the absence of normal bile canalicular CD10 staining in some cases of primary liver cell carcinoma. Our aim was to investigate the possibility that this loss of staining occurs prior to the development of cancer.

Primary glial tumor of the retina with features of myxopapillary ependymoma.

We report a primary retinal tumor with features of myxopapillary ependymoma. The lesion occurred in a 33-year-old man with a long history of phthisis bulbi and a more recent history of pain to the right eye. Enucleated ocular globe revealed a lesion occupying most of the retinal surface. Histologically, the retina was replaced by a tumor composed of spindle cells with fibrillary cytoplasm and round to ovoid nuclei forming fascicles, perivascular pseudorosettes, microcysts, and deposition of extracellular mucins. Calcifications, metaplastic bone, and lymphoplasmacytic inflammatory infiltrate were also seen. Tumor cells expressed GFAP and S-100 and to lesser extent carbonic anhydrase II. The immunoreaction for EMA showed diffuse granular positivity, decorated a few extracellular lumina, and highlighted intracytoplasmic lumina in a few cells. Ultrastructurally, there was accumulation of extracellular material between cells and around capillaries, long interdigitating cytoplasmic processes, extracellular lumina packed with microvilli, a few junctions evident around lumina, and some ciliary basal bodies and ciliary basal rootlets. As control cases, we also investigated expression of EMA and carbonic anhydrase II in an ocular globe with retinal gliosis and three cases of myxopapillary ependymoma of the cauda equina. The lesion described here represents the first example of retinal tumor with features of myxopapillary ependymoma. Pathologic features and particularly expression of carbonic anhydrase II suggest a derivation from intrinsic glial cells of retina otherwise known as Muller cells.

Triple negative, basal cell type and EGFR positive invasive breast carcinoma in Kuwaiti and British patients.

To the Editor: Geographic and ethnic variation in the incidence of various types of breast carcinoma are known to exist. We were therefore interested in finding out whether or not there are differences in the incidence of triple negative breast carcinoma and epidermal growth factor receptor (EGFR) positive tumors between patients from a Middle Eastern Country as compared with a Western Country, as this might have implications concerning health planning strategies. Eighty eight patients with invasive breast carcinoma were studied. These included 38 consecutive patients from The University of Kuwait Hospital, including one with bilateral tumors, and 50 consecutive patients from Charing Cross Hospital, London (CX). For each tumor new 5 l-thick paraffin sections were cut and stained for estrogen receptor (ER) (Novocastra, concentration 1:200), progesterone receptors (PgR) (Launch Diagnostics, 1:200), HER2 (Dako, 1:200), cytokeratin 5 ⁄ 6 (Dako, 1:200), and EGFR (Novocastra, 1:200), using standard avidin–biotin immunoperoxidase technique. Because of insufficient tumor tissue in the paraffin blocks of some cases, a few cases were stained for a limited number of these antibodies. For ER and PgR, the histochemical scoring assessment system was used (1), where the percentage of stained tumor cells was multiplied by a factor reflecting the intensity of staining (1 for weak, 2 for moderate, and 3 for strong staining). The results could thus range from 0 (no positively stained tumor cells) to 300 (strong staining of 100% of tumor cells). A minimum score of 30 is needed to consider the case positive. For HER2 and EGFR, a case is considered positive if more than 10% of tumor cells showed strong membrane staining. For cytokeratin 5 ⁄ 6, strong cytoplasmic staining of 10% of tumor cells at least was required to consider the case positive. For statistical comparison, Fisher’s exact test was used. The age of the Kuwaiti patients ranged between 30–70 years with a mean of 50.4. For CX patients the range was 31–79 and the mean 57.7 years. In particular, 16 (42%) out of the 38 Kuwaiti patients were under the age of 50, compared with 11 ⁄ 50 (22%) CX patients. The Fisher’s p-value is 0.06 which is weakly significant. The incidence of the two main histological types, i.e., invasive ductal (77% for Kuwaitis and 78% for CX) and lobular carcinoma (10% and 12% respectively), was similar in both populations. Each of the two studied cohorts included a single case of mucinous carcinoma and another of metaplastic carcinoma. However, medullary carcinoma was present in three (8%) Kuwaiti patients, (two typical and one atypical with partly infiltrative borders), and in none CX patients; while no tubular carcinomas were seen in Kuwaiti patients compared with three (6%) CX cases. The Kuwaiti patients had a higher incidence of grade III tumors (16 ⁄ 39, 56%), compared with CX patients (12 ⁄ 50, 24%); with a p-value of 0.11. Grade I tumors were less common in Kuwaiti patients (4 ⁄ 39, 10%) than in CX patients (10 ⁄ 50, 20%), but the incidence of grade II tumors was not markedly different (19 ⁄ 39; 49% versus 28 ⁄ 50; 56%, respectively). Axillary lymph node metastasis were present in 22 (59%) out of the 37 Kuwaiti patients who underwent axillary dissection, compared with 20 (40%) out of the 50 CX patients who all had axillary dissection. The Fisher’s p-value is 0.14, which is weakly positive. The incidence of ER and PgR positive tumors was similar in the Kuwaiti and CX populations (79% versus 78% for ER and 45% versus 48% for PgR; respectively), and there was no statistical difference between the incidence of cytokeratin 5 ⁄ 6 (16% versus 15%; Fig. 1) and EGFR (15% versus 12%; Fig. 2) positive tumors. HER2 positivity was higher in Kuwaiti than in CX patients (8 ⁄ 39, 21% versus 4 ⁄ 50, 8% respectively, Fisher’s p-value 0.12). Address correspondence and reprint requests to: Sami Shousha, MD, Department of Histopathology, Charing Cross Hospital, Fulham Palace Road, London W68RF, or e-mail: s.shousha@imperial.ac.uk

Comparison of immunoperoxidase staining of 3 different types of CD5 antibodies in a spectrum of breast lesions.

CONTEXT We recently described a patient with chronic lymphocytic leukemia who presented with a breast carcinoma that stained positive for CD5 using a commercially available antibody (CD5-4C7, Novocastra, Newcastle upon Tyne, UK). OBJECTIVES To study the distribution of CD5 immunoreactivity in tissue sections of a variety of benign and malignant breast lesions using the antibody CD5-4C7 and to compare the results with those obtained with 2 other commercially available CD5 antibodies (CD5/54/F6, Dako, Ely, Cambridgeshire, UK, and CD5/54/B4, Novocastra). DESIGN Paraffin sections of 102 breast biopsy specimens with various diagnoses were examined using the avidin-biotin immunoperoxidase complex technique. SETTING The histopathology department of a tertiary referral teaching hospital. RESULTS The staining results obtained with CD5-4C7 were different from those obtained with the other 2 antibodies. With 4C7, the normal and benign biopsy specimens showed varying numbers of positive epithelial cells and lymphocytes. Heterogeneous positive staining was also present in 47 (78%) of 60 invasive female breast carcinomas and in all 3 male breast carcinomas examined. A statistically significant correlation was found between CD5 positivity and tumor grade, with grade 3 tumors being less likely to be CD5 positive than grades 1 and 2 (P =.0035). No correlation was found between CD5 positivity and patients age, tumor histologic type, axillary lymph node status, or progesterone receptors. On the other hand, the CD5/54/F6 and CD5/54/B4 antibodies only stained lymphocytes and occasional normal breast ducts, mostly those showing apocrine metaplasia. All other normal benign and malignant epithelial cells were negative. CONCLUSIONS Positive staining for CD5 using the antibody 4C7 is seen in normal and benign breast tissue and 78% of invasive breast carcinomas. The positivity is more common in low-grade tumors. No significant staining was seen with the 2 other CD5 clones used in this study. The significance of the positive staining obtained with CD5-4C7 is not obvious, but this clone may be more sensitive than the others, or it may be recognizing an epitope shared by another antigen.

Epidermal growth factor receptor status in early stage breast cancer is associated with cellular proliferation but not cross-talk.

The epidermal growth factor receptor (EGFR) is a therapeutic target in a number of settings in solid malignancies, but its role in breast cancer has remained unclear and controversial. In 810 primary breast cancers derived from patients suitable for cytotoxic chemotherapy, EGFR was prospectively measured and interactions with tumour and clinical correlates were tested to observe whether postulated cross-talk mechanisms are likely to modulate breast cancer metastasis and proliferation. A minority (79 tumours, 9.8%) were EGFR positive; in a multivariate analysis the likelihood of being EGFR positive was significantly increased for patients with grade 3 disease, compared with grade 1 (OR 15.6; 95% CI 2 to 122, p=0.0001), and for oestrogen receptor-negative status compared with positive (OR 24.1; 95% CI 12.7 to 46.00, p=0.0001). EGFR expression may play a role in breast cancer proliferation, but appears unlikely to modify tumour pathology via postulated mechanisms of oestrogen receptor/EGFR-mediated cross-talk.

October 2006: a 37-year old male with headache.

© 2007 The Authors Journal Compilation

An unusual triple-negative breast carcinoma

1. Nucci MR, Clement PB, Young RH. Lobular endocervical glandular hyperplasia, not otherwise specified: a clinicopathologic analysis of thirteen cases of a distinctive pseudoneoplastic lesion and comparison with fourteen cases of adenoma malignum. Am. J. Surg. Pathol. 1999; 23; 886–891. 2. Mikami Y, Hata S, Melamed J et al. Lobular endocervical glandular hyperplasia is a metaplastic process with a pyloric gland phenotype. Histopathology 2001; 39; 364–372. 3. Mikami Y, Kiyokawa T, Hata S et al. Gastrointestinal immunophenotype in adenocarcinomas of the uterine cervix and related glandular lesions: a possible link between lobular endocervical glandular hyperplasia ⁄ pyloric gland metaplasia and ‘adenoma malignum’. Mod. Pathol. 2004; 17; 962–972. 4. Kawauchi S, Kusuda T, Liu XP et al. Is lobular endocervical glandular hyperplasia a cancerous precursor of minimal deviation adenocarcinoma?: a comparative molecular-genetic and immunohistochemical study. Am. J. Surg. Pathol. 2008; 32; 1807–1815. 5. Zaino RJ. Symposium part I: adenocarcinoma in situ, glandular dysplasia, and early invasive adenocarcinoma of the uterine cervix. Int. J. Gynecol. Pathol. 2002; 21; 314–326. 6. Cina SJ, Richardson MS, Austin RM et al. Immunohistochemical staining for Ki-67 antigen, carcinoembryonic antigen, and p53 in the differential diagnosis of glandular lesions of the cervix. Mod. Pathol. 1997; 10; 176–180. 7. Mittal K. Utility of proliferation-associated marker MIB-1 in evaluating lesions of the uterine cervix. Adv. Anat. Pathol. 1999; 6; 177–185.