Different lab reports for ER / PR

[anshul_15]

Dear all,

My mother (age 52) is a patient of Breast Cancer- T2N0M0 [IDC - infiltrating ductal carcinoma (NOS) grade III, MBR score (8/9)].

Her tumor was tested (post surgery) for ER, PR and Her2-neu. Second opinion was also taken on blocks and slides. But to our surprise, both reports are different.

The first report is of MAX hospital Delhi and the second report is from Oncquest Laboratories, Delhi.

Report 1: IHC performed

ER – Negative with Allred Score 0/8

PR- Negative with Allred Score 0/8

Her2neu- Positive with Score 3+

P53 – about 35% to 40% (nuclear positivity)

Ki67- about 25% to 28% (proliferation index)

Report 2: IHC performed

ER- Positive with parameters: [ % cells= 15 % and intensity= moderate]

PR- Negative with parameters: [ % cells= 00 % and intensity= NA]

Her2neu – Positive ( FISH positive)

P53- Positive weak to moderate in 10% cells.

Ki67- about 60%

The first report says that ER is negative while the second report says that ER is positive. What should be done in this case - Should my mother take hormonal therapy after her chemotherapy and radiation therapy?

Also we can see differences in Ki67 and p53. How to attribute to these differences ?

Should I get a third opinion? and from where ? Please suggest any place from where I can get a bench mark report.

I have heard about whole genomic analysis (molecular testing) for breast cancer. Should we get it done ? What is it actually ? Will I get confirmed results from this test? Where should I send the blocks and slides for genomic/molecular testing ?

Thank you.

[sumeet_shah Administrator]

If you wish, you can get it reviewed from Tata Memorial Hospital, Mumbai. I cannot think of a better place than this for the review.

[roxboxfox RadiationOncologist]

The concordance between 2 results is known to be 85% for Estrogen Receptor

There is known tumour heterogeneity and though both hospital have used IHC, there is slight difference in the way they are performed and there are additional factors which influence results.

The fact that Oncquest has detected Estrogen staining immunoreactive cells, means she will Benefit from Hormone therapy.

There will also be benefit from Trastuzumab based treatment along with Chemo and radiation for her.

I would personally offer Hormone therapy to your mother if I was your Oncologist

All the best

[anshul_15 in reply to roxboxfox]

Thank you sumeet sir and rohit sir .....

Sir, I want to know for sure shot whether ER is positive or not, so should we go for whole genome (molecular testing) analysis for markers of breast cancer. Can this testing rule out any confusion regarding false positive or false negative result ?

Sir, is this method really helpful and do people go for it ?

Or should I send the blocks / slides to TMH Bombay for third opinion. Sir, there is also an international diagnostic company called QUEST Diagnostics; sir which would be better- sending blocks to TMH or QUEST ?

Sir, does this 15% moderate positive ER result really matter to go hormone therapy considering that fact that another lab has given negative result for ER. [ PR negative in both the cases].

Thank you and regards.

[roxboxfox RadiationOncologist]

Well Anshul,

Tumour Heterogenieity = is the observation that different tumour cells can show distinct morphological and phenotypic profiles, including cellular morphology, gene expression, metabolism, motility, proliferation, and metastatic potential.

en.wikipedia.org/wiki/Tumou...

You first need to find out the cost of this molecular typing ?

Her 2 positive breast cancer, is not a licensed indication for this molecular typing

In a heterogenous tumour, if you test that portion of the specimen which has no estrogen receptor expression, that report will shown ER receptor -ve

However, if you test that portion of tumour which has Estrogen receptor expression, then that report will be positive.

As per the ASCO guidelines, if the tumour exhibits > 1% expression of ER, it is considered Positive

A tumour is considered -ve for ER, if it exhibits < 1% expression of ER

cap.org/apps/docs/laborator...

Please read the optimal conditions of testing and you will realise there are so many reasons why this results may differ, in addition to the most probable reason of Tumour Heterogenieity

As per Std Guidelines, from the report of Oncquest Laboratories, she merits Hormone Therapy

You may get this tested at different lab, and can take further opinion. That is certainly your choice and you have to decide, that if this was also negative, would you Not have Hormone therapy, as as an oncologist the Hormone therapy options will still be your option given the fact that one reputed Lab has demonstrated ER positivity.

The WORSE CASE SCENARIO

God forbid if the cancer came back 2 or 3 years later, and this cancer was ER positive and you had opted out of Hormone therapy, whom would you blame, yourself, the laboratory or the oncologist.

These are the difficult decisions we do face at times, and as an Oncologists we would rather overtreat than undertreat as we wish well for patients and do not want to be sued. This is preventive oncology.

Can you please disclose your oncologists opinion as to what would he do if it was his mother or sister, and perhaps you will get your answer.

[anshul_15 in reply to roxboxfox]

That was so wonderfully explained rohit sir....awesome.... Now I get the point.

Our treating medical oncologist is in favour of giving benefit of doubt to the patient, that is he wishes to give hormonal therapy afterwards. But at the same time he asked us to go for complete breast cancer genomic analysis (molecular testing) to know what type of markers are present, if we wish to. Thats why I was asking.

Thank you so so much.... it really helped a lot.