Introduction and Breast Cancer Statistics Prognostic Factors Tumor Grade and Type Lymph Node Status Distant Metastases Gene Markers Hormone Receptors Growth Factor Receptor Tumor Suppressor Gene Proliferation Marker Angiogenesis Marker Summary & Conclusion

1. 1
Rev. 29
PROGNOSTIC MARKERS INPROGNOSTIC MARKERS IN
BREAST CANCERBREAST CANCER

2. 2
OutlineOutline
 Introduction and Breast Cancer Statistics
 Prognostic Factors
Tumor Grade and Type
Lymph Node Status
Distant Metastases
 Gene Markers
Hormone Receptors
Growth Factor Receptor
Tumor Suppressor Gene
Proliferation Marker
Angiogenesis Marker
 Summary & Conclusion

3. 3
Breast Cancer - IntroductionBreast Cancer - Introduction
Cells in the breast tissue divide and grow without control
80% of cases of breast cancer originate in the mammary
ducts
20% cases arise in the lobules
There are 2 main kinds of breast cancer:
Invasive breast cancer
carcinoma in situ

4. 4
OVERVIEWOVERVIEW
BREAST CANCER FACTS & FIGURES
 New cases diagnosed in American women in 2002 : 203,500
 New cases of invasive breast cancer in 2001: 192,200
 Breast Cancer affects more than 1000 men in this country each year
 An estimated 40,200 deaths occurred in 2001
 Overall survival rate is 18% if cancer has metastasized
 Early diagnosis is critical
 Overall 5-year survival rate: 96%

5. 5
PROGNOSTIC FACTORS
 Prognostic Factors are clinical, pathologic, and biological
features of cancer patients and their tumors that forecast
probable course and outcome of the disease.
 Predicts the likelihood of patient survival.
 Predicts recovery from cancer without additional or adjuvant
systemic therapy after initial surgery.

6. 6
BREAST CANCERBREAST CANCER
HIGHLY ELEVATED RISK FACTORS
 Female
 Age >50
 North American or Northern European ancestry
 Personal history of prior breast cancer
 Family history of bilateral, pre-menopausal, or familial cancer
 Atypical proliferative breast disease with family history

7. 7
BREAST CANCERBREAST CANCER
MODERATELY ELEVATED RISK FACTORS
 Any first degree relative with history of breast cancer
 Upper social / economic class
 Prolonged uninterrupted menses
 Postmenopausal obesity
 Proliferate benign breast disease

8. 8
BREASTBREAST
CANCERCANCERSLIGHTLY ELEVATED RISK FACTORS
 Moderate alcohol intake
 Menarche: <12 years old
 Diet (?)
 Hormonal Replacement Therapy (?)
 Birth control pills (?)

9. 9
• T1
Tumour ≤2cm in greatest dimension
• T2
Tumour 2-5 cm in greatest dimension
• T3
Tumor >5 cm in greatest dimension
• T4
Fixation to chest wall; edema;
skin ulceration; inflammatory breast cancer;
peau d’orange; satellite skin nodules
PROGNOSTIC FACTORSPROGNOSTIC FACTORS
PRIMARY TUMOR SIZE

10. 10
PROGNOSTIC FACTORSPROGNOSTIC FACTORS
TUMOR GRADETUMOR GRADE
 Pathologists determine how close the cancer cells resemble
normal tissue
 The more abnormal the cells, the higher the grade of the tumor
 High-grade tumors are more likely to spread to lymph nodes
and other parts of the body
 Also determine the number of cancer cells in the process of
dividing - assess the growth rate of the tumor
 The higher the grade of the tumor - the worse a woman’s
prognosis

11. 11
• N0
No palpable regional lymph nodes
• N1
Palpable ipsilateral axillary nodes, movable
• N2
Palpable ipsilateral axillary nodes, fixed
• N3
Metastases to ipsilateral mammary nodes
PROGNOSTIC FACTORSPROGNOSTIC FACTORS
LYMPHATIC SPREAD

12. 12
• Mx
Distant metastases cannot be assessed
• M0
No distant metastases
• M1
Distant metastases present
PROGNOSTIC FACTORSPROGNOSTIC FACTORS
DISTANT METASTASES

13. 13
PROGNOSTIC FACTORSPROGNOSTIC FACTORS
TNM STAGING
STAGETNM0TisN0M0IT1N0M0IIAT0N1M0T1N1M0T2N0M0IIBT2N1M0T3N0M0IIIAT0N2M0T1

14. 14
HORMONE RECEPTORSHORMONE RECEPTORS
ESTROGEN RECEPTOR (ER)
 Estrogen, by interacting with ER, plays a central role in regulating the
proliferation and differentiation of normal breast epithelium
 Approximately 60-70% of breast cancers express ER
 ER is localized in the nucleus only
 Estrogen binds to its receptor (i.e. ER) and the complex then activates
DNA synthesis
 Primary reason for measuring ER in breast cancer is the ability to
predict response to endocrine therapy

15. 15
HORMONE RECEPTORSHORMONE RECEPTORS
ESTROGEN RECEPTOR (ER)
 Survival statistics are improved in patients with receptor positive
tumours
 Recurrence/survival benefit after diagnosis is 10% for patients with
ER(+) tumors who did not receive adjuvant therapy
 There is a 20-30% average reduction in recurrence/mortality in ER(+)
patients receiving adjuvant endocrine therapy
 There is a 60% overall clinical response rate in patients with ER(+)
advanced breast cancer treated with endocrine therapy

16. 16
HORMONE RECEPTORSHORMONE RECEPTORS
ESTROGEN RECEPTOR (ER)
• Breast carcinoma stained with anti-ER MAb
(ER88 / BioGenex)
• This antibody stains human nuclear ER

17. 17
HORMONE RECEPTORSHORMONE RECEPTORS
PROGESTERONE RECEPTOR (PgR)
 PgR is an ER-regulated gene product with many of the same
prognostic/predictive implications as ER in breast cancer
 PgR is an estrogen-inducible protein, of which expression is
indicative of an intact ER pathway.
 PgR may identify tumours that are hormonally responsive to
estrogen, thereby improving the overall predictive value of
steroid receptor IHC

18. 18
HORMONE RECEPTORSHORMONE RECEPTORS
PROGESTERONE RECEPTOR (PgR)
• PR88 (BioGenex) stains the nucleus of carcinoma
cells but not surrounding connective tissue
• Microwave pretreatment with Antigen Retrieval
Citra solution of formalin-fixed, paraffin
embedded breast tissue sections is recommended

19. 19
Receptor Content Incidence Response Rate
ER(+) / PR(+) 50 77%
ER(-) / PR(+) 5 46%
ER(+) / PR(-) 20 27%
ER(-) / PR(-) 25 11%
• PR may be a more important predictor as there
are more responders among patients with
ER(-)/PR(+) compared to ER(+)/PR(-) tumours.
STEROID RECEPTORSSTEROID RECEPTORS
ER & PgR INCIDENCE &
RESPONSE TO THERAPY

20. 20
GROWTH FACTOR RECEPTORGROWTH FACTOR RECEPTOR
c-erbB-2 (Her-2/neu)
 c-erbB-2 (Her-2/neu) is a gene located on chromosome 17q12 -
21.32, encoding a 185 kDa protein
 c-erbB-2 (Her-2/neu) oncoprotein is a member of the tyrosine
kinase receptor
 c-erbB-2 (Her-2/neu) oncoprotein is thought to function as a
growth factor receptor, in addition to being involved in the
regulation of cellular differentiation, adhesion, and motility

21. 21
GROWTH FACTORGROWTH FACTOR
RECEPTORRECEPTORc-erbB-2 (Her-2/neu)
 c-erbB-2 (Her-2/neu) is amplified and/or overexpressed in 25 -
30% of invasive breast cancers
 c-erbB-2 (Her-2/neu) overexpression is correlated with an
increased cell proliferation rate and poorer overall survival
 c-erbB-2 (Her-2/neu) overexpression is inversely related to
Estrogen Receptor (ER) expression

22. 22
GROWTH FACTOR RECEPTORGROWTH FACTOR RECEPTOR
c-erbB-2 (Her-2/neu)
 There is a direct correlation between c-erbB-2 (Her-2/neu)
overexpression and resistance to cytoxan/methotrexate therapy
 c-erbB-2 (Her-2/neu) overexpression is also linked to tamoxifen
resistance
 Increased levels of c-erbB-2 (Her-2/neu) might enhance
response to adriamycin
 In certain situations, patients with an amplified c-erbB-2 status
will qualify for specialized therapies, such as Herceptin

23. 23
GROWTH FACTOR RECEPTORGROWTH FACTOR RECEPTOR
c-erbB-2 (Her-2/neu)
• Breast carcinoma stained with anti-c-erbB-2
(Clone CB11 / BioGenex)
• The specific binding of this MAb has been
demonstrated by immunoprecipitation using
c-erbB-2 protein from SKB-3 cells

24. 24
TUMOUR SUPPRESSOR GENETUMOUR SUPPRESSOR GENE
p53 GENE
 p53 is a tumor suppressor gene whose protein product is a
nuclear transcription factor with many functions, including
arresting cell cycle progression
 p53 mutations lead to abnormal cell growth by failing to trigger
cell suicide when DNA repair fails
 Mutant p53 are point mutations in conserved exons, resulting in
a nonfunctional but more stable protein that accumulates to high
levels in the nucleus

25. 25
TUMOUR SUPPRESSOR GENETUMOUR SUPPRESSOR GENE
p53 GENE
 Mutant p53 correlates with more aggressive tumor behaviour,
metastases, and lower 5-year survival rates
 p53 mutations have been found in more than 50 types of human
tumours, including 70% of colorectal cancers, 50% of lung
cancers, and 40% of breast cancers

26. 26
TUMOUR SUPPRESSOR GENETUMOUR SUPPRESSOR GENE
p53 GENE
 Mutant p53 is a strong and independent prognostic factor that is
very good at detecting high-risk patients, but not very good at
defining patients with a low enough risk to alter standard therapy
 Oncologists still order p53 analysis on breast cancers and use the
results to help make treatment decisions for patients whose
outlook is borderline or complicated by other factors

27. 27
TUMOUR SUPPRESSOR GENETUMOUR SUPPRESSOR GENE
p53 GENE
• Breast carcinoma stained with anti-p53
(Clone BP53-12-1 / BioGenex)
• Shows primarily a nuclear localization of mutant
p53 protein

28. 28
PROLIFERATION MARKERPROLIFERATION MARKER
Ki-67
 Ki-67 is a 345-395 kD non-histone protein-protein complex
 The gene encoding Ki-67 is localized on chromosome 10 and
organized in 15 exons
 Expression of human Ki-67 protein is strictly associated with cell
proliferation

29. 29
PROLIFERATION MARKERPROLIFERATION MARKER
Ki-67
 Ki-67 expression is correlated with relapse-free survival, histologic
grade, and mitotic figure count
 Ki-67 expression is inversely associated with the presence of ER
and PR in breast carcinomas and the survival rate
 Ki-67 is more likely to be expressed in aneuploid tumours
compared to diploid tumours

30. 30
PROLIFERATION MARKERPROLIFERATION MARKER
Ki-67
• Malignant lymphoma stained with anti-Ki-67
(Clone Ki88 / BioGenex)
• This MAb reacts with the Ki-67 antigen localized
in nuclei of proliferating cells

31. 31
ANGIOGENESISANGIOGENESIS
Factor VII RA
 Factor VIII RA remains a sensitive marker of benign blood vessels
and has been used for the study of angiogenesis in neoplasms
such as breast cancer
 Angiogenesis is the process leading to the formation of new blood
vessels, necessary for tumour growth and metastasis

32. 32
ANGIOGENESISANGIOGENESIS
Factor VII RA
 Factor VIII RA (Related Antigen) is more appropriately known as
the von Willebrand factor
 Factor VIII is a glycoprotein and is complexed with factor VIII-RA
in plasma
 Factor VIII RA is a useful marker for endothelial cell
differentiation

33. 33
ANGIOGENESISANGIOGENESIS
Factor VII RA
• Blood vessels stained with anti-Factor VIII
(Clone BGX016A / BioGenex)
• Note the staining of endothelial cells

34. 34
SUMMARYSUMMARY
FACTORS DEFINING POOR PROGNOSIS
 Histological Grade 3
 Tumor Size: >5.0 cm
 Lymph Node Status: N>0
 ER (-) and PR (-)
 p53 (+)
 c-erbB-2 (+)
 Ki-67: High Proliferation Rate
 Factor VIII RA: (+)

35. 35
CONCLUSIONCONCLUSION
 Tumor size and nodal status should be reported on all breast
cancers, because they are currently the only prognostic factors
that are comprehensively validated and powerful enough to
identify a subset of patients whose predicted outcome is
sufficiently favorable to justify withholding adjuvant
chemotherapy.
 Hormone receptors should also be assessed in every case,
because they are the only predictive factors with proven
usefulness in selecting patients likely to respond to adjuvant
endocrine therapy.