Yanjun Hou

Impact of the Afirma Gene Expression Classifier Result on the Surgical Management of Thyroid Nodules with Category III/IV Cytology and Its Correlation with Surgical Outcome

Objective: The Afirma gene expression classifier (GEC) is a molecular test to further classify indeterminate fine-needle aspiration (FNA) as benign or suspicious for malignancy. Study Design: A total of 158 FNAs with Bethesda category III/IV cytology were sent for an Afirma GEC test. We correlated the Afirma GEC results with surgical outcome and also compared the data after Afirmas implementation with the data before. Results: Among the 158 FNAs, the Afirma result was benign in 63 (40%), suspicious in 85 (54%) and unsatisfactory in 10 (6%). In total, 73 (86%) suspicious Afirma cases had surgery and 28 (38%) showed carcinoma. In contrast, only 8 (13%) benign Afirma cases had surgery and all of them were benign. The sensitivity, specificity, negative predictive value and positive predictive value (PPV) of Afirma were 100, 15, 100 and 38%, respectively. The PPV was 20% in cases with follicular lesion of undetermined significance, but was 50% in cases suspicious for follicular neoplasm (SFN). The surgical excisional rate was significantly decreased in SFN cases after the Afirma test. Conclusions: The Afirma GEC is useful for further risk stratifying SFN cases.

Surgical excision outcome after radial scar without atypical proliferative lesion on breast core needle biopsy: a single institutional analysis.

Radial scar (RS) has been recognized as a risk factor for developing breast cancer, and excision is recommended for patients with RS identified on core needle biopsy (CNB). However, recent literatures suggest that the increased risk may be caused by concurrent proliferative lesions on the biopsy, rather than radial scar itself. In this study, we investigated the follow-up excision (FUE) results for patients with RS on CNB with no history of a prior or a concurrent breast cancer or atypical proliferative lesions (APLs). A total of 113 RS cases including 32 cases with APLs or carcinoma and 81 cases without APLs on CNB were included in this study. Forty cases (49%) without APLs had FUE. No significant difference in radiologic and clinical findings was identified between cases with FUEs and cases without FUEs. Of the 40 cases with FUE, 9 cases (22.5%) were upgraded including 3 atypical ductal hyperplasias, 4 lobular neoplasias, 1 flat epithelial atypia, and 1 atypical apocrine adenosis. However, no case was upgraded to invasive carcinoma or ductal carcinoma in situ. All cases with mammotome CNBs were not upgraded. Our data suggest that conservative follow-up with imaging rather than surgical excisions may be more appropriate for patients with only RS on biopsy, especially for patients with mammotome CNBs.

Fine‐needle aspiration of cervical lymph nodes yields adequate materials for accurate HPV testing in metastatic head and neck squamous cell carcinomas

High‐risk Human papillomavirus (HR‐HPV)‐associated head and neck squamous cell carcinoma (HNSCC) is a distinct epidemiologic and pathologic disease. The data of HR‐HPV testing on fine‐needle aspiration (FNA) materials of cervical lymph nodes in patients with metastatic HNSCC are limited.

Evaluation of immune reaction and PD-L1 expression with multiplex immunohistochemistry in HER2-positive breast cancer: the association with response to anti-HER2 neoadjuvant therapy

Background: Immune reaction with tumor‐infiltrating lymphocytes (TILs) has been extensively investigated in breast cancer. Programmed cell death 1 and its ligand (PD‐L1) are key physiologic suppressors of cytotoxic immune reaction. However, the combination of TILs with PD‐L1 expression has not been well studied in breast cancer. Patients and Methods: A multi‐color immunohistochemical multiplex assay simultaneously detecting PD‐L1, CD8, and CD163 was performed on biopsy whole sections from 123 HER2‐positive (HER2+) breast cancers, including 64 treated with anti‐HER2 neoadjuvant therapy and subsequent resection. Results: PD‐L1 expression was identified in 88 cases (72%) including 21 (17%) in tumor cells and 67 (55%) in immune cells. PD‐L1 expression was positively associated with high Nottingham grade, high nuclear grade, and a high level of CD8+ and CD163+ cells. Among the 64 patients who received neoadjuvant therapy, 39 had pathologic complete remission (pCR) and 25 had incomplete response. Multivariate analysis showed progesterone receptor negativity, HER2/chromosome 17 centromere (CEN17) ratio and intratumoral CD8+ cells were significantly associated with pCR. Furthermore, all patients with intratumoral CD8+ cells but no PD‐L1 expression achieved pCR. Conclusion: Our data have shown that examination of intratumoral CD8+ cells together with PD‐L1 expression proves useful in predicting response to anti‐HER2 targeted therapy in patients with HER2+ breast cancer.

HER2 intratumoral heterogeneity is independently associated with incomplete response to anti-HER2 neoadjuvant chemotherapy in HER2-positive breast carcinoma

PurposeAnti-HER2 neoadjuvant chemotherapy has been widely used in HER2-positive breast cancer patients; however, pathologic complete response (pCR) is achieved in only 40–50% of patients. The aim of this study was to investigate the association of HER2 intratumoral heterogeneity (ITH) with response to anti-HER2 neoadjuvant chemotherapy.MethodsAssessment of HER2 ITH was performed on whole tissue sections of pre-treatment samples from a cohort of 64 invasive breast carcinoma cases originally considered positive for HER2 and treated with anti-HER2 neoadjuvant chemotherapy. Both HER2 gene signal and protein expression were simultaneously evaluated by means of a single-slide dual assay, designated as a HER2 gene-protein assay (GPA). HER2 GPA was carried out as well on surgical resection tissues from 25 cases with incomplete therapeutic response.ResultsNineteen of 64 cases (30%) showed HER2 ITH. Significantly more cases with HER2 ITH were found in the incomplete response group (56%, 14/25) than in the pCR group (13%, 5/39). Patients without ITH detectable by GPA had a 76% pCR outcome (34/45), as compared to 26% (5/19) for those with detectable ITH. Multivariate analysis demonstrated HER2 ITH, progesterone receptor positivity, and relatively low HER2/chromosome 17 centromere ratio to be significantly associated with incomplete response.ConclusionsHER2 ITH analyses conducted with GPA method revealed that HER2 ITH is an independent factor predicting incomplete response to anti-HER2 neoadjuvant chemotherapy.

Comparison of Oncotype DX With Modified Magee Equation Recurrence Scores in Low-Grade Invasive Carcinoma of Breast

Objectives Several specific histologic types of invasive carcinoma of breast, including invasive tubular carcinoma (ITC), invasive mucinous carcinoma (IMC), and classical invasive lobular carcinoma (CILC), are considered low-grade carcinomas with favorable outcomes. We aimed to investigate the utility of Oncotype DX test in these tumors by comparing its recurrence score (RS) with the modified Magee equation RS. Methods Oncotype DX RSs were collected and modified Magee equation RSs were calculated in 163 low-grade invasive breast carcinomas, including 105 CILCs, 41 ITCs, and 17 IMCs. Results In total, 105 (64.4%) cases had an Oncotype DX RS less than 18, 56 (34.4%) were between 18 and 30, and two (1.2%) were more than 30. Of the cases, 124 (76.1%) had a modified Magee RS less than 18, 39 (23.9%) were between 18 and 30, and no case was more than 30. The overall agreement between Oncotype DX RS and modified Magee RS risk categories was 68.7%. Two CILCs with an Oncotype DX RS more than 30 had modified Magee equation RSs of 20.3 and 20.0, respectively, and both had not shown recurrent disease. Conclusions Performing Oncotype DX on low-grade invasive carcinomas is unlikely to provide additional useful information beyond Magee equation RS, and eliminating Oncotype DX from these cases could lead to substantial cost savings.

HER2 Gene Protein Assay Is Useful to Determine HER2 Status and Evaluate HER2 Heterogeneity in HER2 Equivocal Breast Cancer.

Objectives: Approximately 15% of breast cancers show equivocal human epidermal growth factor receptor 2 (HER2) results on HER2 immunohistochemistry (IHC) and are reflexed for fluorescence in situ hybridization (FISH). However, some cases remain equivocal. In this study, we evaluated these double-equivocal cases by using a novel gene protein assay (GPA), which can simultaneously assess HER2 gene copy number and protein on a single slide using bright-field microscopy. Methods: GPA was performed on 42 HER2 IHC and FISH double-equivocal cases. Results: GPA was negative for amplification in 28 cases, equivocal in three cases, and positive in 11 cases. The GPA results showed excellent concordance with either repeat FISH using a chromosome 17 centromere probe or FISH using an alternative probe. Furthermore, HER2 heterogeneity was identified in three of 11 GPA-positive cases. Conclusions: HER2 GPA performs accurately and is very useful to determine HER2 status in HER2 IHC and FISH double-equivocal breast cancer cases and identify HER2 heterogeneity.

Using the Modified Magee Equation to Identify Patients Unlikely to Benefit From the 21-Gene Recurrence Score Assay (Oncotype DX Assay)

Objectives This study aimed to compare a modified Magee equation with Oncotype DX (Genomic Health, Redwood City, CA) recurrence score (RS) and identify patients who are unlikely to benefit from Oncotype DX. Methods Magee equation RS was calculated in 438 cases and correlated with Oncotype DX RS. Results The Pearson correlation coefficient ( r ) for the Magee equation and Oncotype DX RS was 0.6645 ( P  < .00001), and the overall agreement was 66.4%. All cases (11.6%) with a Magee equation RS greater than 30 or 11 or less had been correctly predicted to have either high Oncotype DX RS or low Oncotype DX RS, respectively. Conclusions The modified Magee equation is able to identify up to 12% patients who are unlikely to benefit from Oncotype DX testing. Using the modified Magee equation RS on these patients would be an alternative to Oncotype DX, leading to cost savings.

Correlation of Expression of Breast Biomarkers in Primary and Metastatic Breast Carcinomas: A Single-Institution Experience

Objective: Changes in the status of estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) in metastatic breast carcinomas are frequently reported. We examined the change in the status of biomarkers in metastatic breast carcinomas. Study Design: This study cohort was composed of 137 metastatic breast carcinomas (58 surgical and 79 cytological specimens) with existing primary tumors during a study period from 2013 to 2015. Results: The overall change rates in metastases were 9, 21 and 6% for ER, PR and HER2, respectively. All changes were from positive in the primary tumor to negative in the metastases. The ER change rate was significantly higher in the cytological than in the surgical metastases. Six of 14 cytological metastases with positive HER2 in primary tumors showed a change in HER2 status, including 5 fluid specimens and 1 fine-needle aspiration (FNA); the other 8 had no change in HER2 status, and included 7 FNAs and 1 fluid specimen. Conclusion: The significant percentage of cases with a change in biomarker status supports the recommendation by the College of American Pathologists to test breast biomarkers in metastases. HER2 status change was mostly identified in fluid specimens; however, the small sample size in our cohort and the fact that HER2 fluorescence in situ hybridization was not performed may warrant further studies.

PD-L1 expression and CD8-positive T cells are associated with favorable survival in HER2-positive invasive breast cancer

Programmed cell death 1 (PD‐1) and its ligand (PD‐L1) are key physiologic suppressors of the cytotoxic immune reaction. However, to date, the combination of PD1/PD‐L1 expression and tumor‐infiltrating lymphocytes (TILs) and antigen‐presenting cells has been only minimally reported in breast carcinoma, in particular in relation to HER2‐positive cases. The goal of this study was to evaluate both cellular tumoral immune reaction and PD‐L1/PD1 distribution in HER2‐positive cases, as well as any associations with clinical outcome using conventional chemotherapy combined with HER2 blocking. Multicolor immunohistochemical multiplex assays simultaneously demonstrating PD1, PD‐L1, and CD8 or PD‐L1, CD3, and CD163 were performed on tissue microarrays (TMA) representing 216 pretreatment cases of HER2‐positive invasive breast carcinoma. PD‐L1 expression was identified in 38 cases (18%), including 12 cases (6%) with PD‐L1 labeling of tumor cells and 26 cases (12%) with PD‐L1 labeling of immune cells only. Ten of 12 cases with PD‐L1 staining of tumor cells showed staining of associated immune cells as well. With this assay method, PD1 was detectable in many fewer cases (6 cases or 3%). PD‐L1 expression was positively associated with high Nottingham grade, negative ER and PR, the absence of lymph node metastasis, and high levels of CD8+ cells. The overall survival by univariate analysis was positively associated with lower tumor stage, the absence of lymph node metastasis, PD‐L1 expression, and high levels of CD8+ cells. Therefore, our data suggest cytotoxic immune reaction mediated by CD8‐positive T cells and PD‐L1 expression may predict a better outcome in patients with HER2‐positive breast carcinoma managed with conventional chemotherapy and HER2‐blocking therapy. These findings recommend clinical trials utilizing checkpoint blocking immunotherapy in some form for HER2‐positive breast cancer.