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An earlier analysis of this phase 3 trial showed that the addition of a cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitor to endocrine therapy provided a greater benefit with regard to progression-free survival than endocrine therapy alone in premenopausal or perimenopausal patients with advanced hormone-receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancer. Here we report the results of a protocol-specified interim analysis of the key secondary end point of overall survival.We randomly assigned patients to receive either ribociclib or placebo in addition to endocrine therapy (goserelin and either a nonsteroidal aromatase inhibitor or tamoxifen). Overall survival was evaluated with the use of a stratified log-rank test and summarized with the use of Kaplan-Meier methods.A total of 672 patients were included in the intention-to-treat population. There were 83 deaths among 335 patients (24.8%) in the ribociclib group and 109 deaths among 337 patients (32.3%) in the placebo group. The addition of ribociclib to endocrine therapy resulted in significantly longer overall survival than endocrine therapy alone. The estimated overall survival at 42 months was 70.2% (95% confidence interval [CI], 63.5 to 76.0) in the ribociclib group and 46.0% (95% CI, 32.0 to 58.9) in the placebo group (hazard ratio for death, 0.71; 95% CI, 0.54 to 0.95; P = 0.00973 by log-rank test). The survival benefit seen in the subgroup of 495 patients who received an aromatase inhibitor was consistent with that in the overall intention-to-treat population (hazard ratio for death, 0.70; 95% CI, 0.50 to 0.98). The percentage of patients who received subsequent antineoplastic therapy was balanced between the groups (68.9% in the ribociclib group and 73.2% in the placebo group). The time from randomization to disease progression during receipt of second-line therapy or to death was also longer in the ribociclib group than in the placebo group (hazard ratio for disease progression or death, 0.69; 95% CI, 0.55 to 0.87).This trial showed significantly longer overall survival with a CDK4/6 inhibitor plus endocrine therapy than with endocrine therapy alone among patients with advanced hormone-receptor-positive, HER2-negative breast cancer. No new concerns regarding toxic effects emerged with longer follow-up. (Funded by Novartis; MONALEESA-7 ClinicalTrials.gov number, NCT02278120.).

The relevant content changes for pathologists in the updated interdisciplinary S3 guideline "Early detection, diagnosis, therapy and aftercare of breast cancer" are explained and discussed in the context of the most recent evidence. These include recommendations for risk assessment using Ki-67 and the use of multigene tests in the decision for or against adjuvant chemotherapy in estrogen receptor(ER)‑/progesterone receptor(PR)-positive and human epidermal growth factor receptor 2 (HER2)-negative invasive breast cancer. In addition, the assessment of HER2 status is explained. It is described which threshold distance or resection margin status is considered sufficient for resection of ductal carcinoma in situ (DCIS) and invasive breast carcinoma. Finally, recommendations concerning the clinical consequences to be drawn from the detection of a risk lesion in a core needle or vacuum biopsy or at the resection margin of a breast surgical specimen are discussed.

Die Bestimmung des Östrogen (ER)- und Progesteronrezeptorstatus (PR) ist Standard bei der Diagnosestellung eines Mammakarzinoms. Sie dient dazu zu definieren, ob ein Tumor endokrin sensitiv ist und die Patientin einer endokrinen Therapie zugeführt werden kann. Der ER hat prognostische und prädiktive Aussagekraft. Die Bedeutung des PR ist weniger klar und wird teilweise kontrovers diskutiert. In der vorliegenden Arbeit wurde die Bedeutung des PR für das Gesamt-, fernmetastasenfreie und lokalrezidivfreie Überleben untersucht. In die Analyse gingen Daten von 5144 Patientinnen mit einem primären Mammakarzinom ein. Untersucht wurde die prognostische Aussagekraft des PR zusätzlich zu Tumorgröße, Nodalstatus, histologischem Tumortyp, Grading und ER. Es konnte gezeigt werden, dass der PR prognostische Bedeutung hat: Das schlechteste Gesamtüberleben wiesen Patientinnen mit einer doppelten Rezeptornegativität auf. In den univariaten Analysen ging ein positiver PR mit einem besseren Gesamt-, lokalrezidivfreien und fernmetastasenfreien Überleben einher, in den multivariaten Analysen mit einem besseren Gesamt- und fernmetastasenfreien Überleben. Die einzige Interaktion zeigte sich zwischen dem ER und PR: Die Subgruppe der Patientinnen mit einem negativen ER und positiven PR wies das signifikant beste fernmetastasenfreie Überleben auf. In der Arbeit konnte die prognostische Bedeutung des PR gezeigt werden. Der PR sollte immer neben dem ER bestimmt werden. Nur so kann die Gruppe an Patientinnen mit negativem ER und positivem PR identifiziert werden, die möglicherweise von einer endokrinen Therapie profitiert.

Gene expression profiling has demonstrated the prognostic relevance of genes associated with proliferation in breast cancer. The immunohistochemical marker Ki-67 enables routine assessment of proliferation activity in pathology. In a number of retrospective but only few prospective studies the prognostic relevance of Ki-67 in breast cancer could be shown. Although there is no standardized approach with regard to which area of a histological section and how many cells should be counted in a quantitative or semiquantitative fashion as well as to the threshold, Ki-67 is broadly applied in breast pathology. This can be explained by the good reproducibility of the degree of proliferation assessed by Ki-67, at least in the low and high ranges, the possibility to substantiate grading and better practicability in core biopsies in comparison to mitotic counting. In neoadjuvant therapy of hormone receptor positive breast cancer, Ki-67 can probably predict the efficacy of pure hormone receptor blockade without chemotherapy.

We report on a case of sebaceous carcinoma of the breast as a rare histological special subtype of breast cancer. Because these tumors are uncommon, differential diagnostic considerations and the exclusion of Muir-Torre syndrome are emphasized. Finally possible mechanisms of development and therapeutic strategies for this carcinoma are discussed.

Molecular biomarker analysis is increasingly being used as a basis for individualized therapy selection. In breast cancer established standard biomarkers are hormone receptors, HER2 and if indicated Ki67. In particular for hormone receptor positive, HER2 negative tumors, gene expression analysis provides additional information on proliferation and hormone receptor signalling. The results of the gene expression tests can be used to identify patients with a very good prognosis under an exclusive endocrine therapy. This group of patients can then be treated without conventional chemotherapy. The EndoPredict assay was validated in two large cohorts from clinical studies of the Austrian breast cancer study group (ABCSG). Furthermore, using a round robin test, the test method was established in several German institutes of molecular pathology. The EndoPredict assay can be carried out in local institutes of pathology and offers additional information to existing standard prognostic parameters.

Tumor biological parameters for the prediction and prognosis of invasive breast cancer are gaining in importance compared to traditional pathological categories. The immunohistochemically determined steroid hormone receptor status is not only the decisive factor influencing whether endocrine therapy (which is indicated in cases of even slight expression) is given or not, but also whether chemotherapy is considered. The Her2 status is of similar importance and needs to be analysed in every case of invasive carcinoma, whereby reproducibility, which requires greater efforts than with steroid hormone receptors, has to be assured. Probably only a small portion of breast cancers will benefit from chemotherapy. Since traditional pathological categories are not sufficient for the identification of this subgroup, there has been an intense search for alternative prognostic parameters, whereby gene expression profiling has emerged as the most promising tool. Despite minimal concordance with regard to single genes, the various profiles available converge in the identification of the proliferative signature as the prognostically most relevant. Whether histopathological grading and immunohistochemical determination of the growth fraction with Ki-67 or genetic profiling will be more reliable in the identification of the aggressive subtype has yet to be clarified in clinical studies which encompass central pathological review.

Endometrial carcinomas can be separated into two groups which are designated as type I and type II carcinomas today. Both groups of tumors are clearly different with regard to conventional light microscopy, immunohistochemistry, molecular pathology and clinical features. Only type I carcinomas are associated with hyperestrogenism. The group of type I carcinomas consists of endometrioid carcinoma and its variants, and mucinous carcinoma. The prototypes of type II carcinomas are serous and clear cell carcinoma. Not all carcinomas, however, can be assigned to one of the two groups, because there are hybrid tumors and mixed carcinomas, e.g. endometrioid carcinoma with a serous component. The precursor lesions of the endometrioid carcinoma and the serous carcinoma are well characterized morphologically and by molecular pathology. Atypical hyperplasia is the precursor lesion of endometrioid carcinoma, whereas endometrial intraepithelial carcinoma (EIC) is the precursor lesion of serous carcinoma. No precursor lesion has as yet been identified for clear cell carcinoma. Immunohistochemical markers for endometrial carcinoma are CK7 and vimentin, for serous carcinoma markers are p53 and p16. Correct typing is of essential prognostic necessity in endometrial carcinoma. Of utmost importance is the detection of a serous component, because serous carcinoma leads to early tumor spread with the necessity of radical surgery, chemotherapy and radiotherapy.

Within the framework of mammography screening programmes the expertise of the pathologist is embedded in an interdisciplinary diagnostic and therapeutic procedure. The quality of histopathological diagnosis not only depends on the expertise of the pathologist, but also requires skillful co-operation with the radiologist and the gynecologist who are both responsible for determining the medical indications for further radiographic and surgical tests and must ensure appropriate tissue samples are taken for non-palpable lesions. Bearing this process in mind it becomes clear that increased expertise in interventional tissue sampling leads to histological samples which are more representative. If the samples are not representative, their histological evaluation does not permit a conclusive statement on the origin of tissue abnormalities shown by mammography. At the mammography unit in Wiesbaden it was demonstrated that breast tissue punches almost always allow a precise histological diagnosis of tissue abnormalities and are at the same time appropriate for additional immunohistochemistry, such as for hormone receptors on carcinoma cells. Non-representative tissue samples are the exception.

Aquaporin1 (AQP1) is a water channel protein which facilitates water flux across cell membranes. AQP1 is found in epithelial and endothelial cells in various tissues. There is increasing evidence that AQP1 is expressed in malignant tumours and that it may play a role in tumour angiogenesis, cell migration and metastasis. We studied the immunohistochemical expression of AQP1 in a cohort of 203 invasive breast carcinomas with long-term follow up. AQP1 expression was detected in 11 cases (5.4%), and showed a significant correlation with high tumour grade, medullary-like histology, "triple-negativity", as well a cytokeratin 14 and actin expression. In univariate analysis, AQP1 was associated with a significantly poorer prognosis. Multivariate analysis showed that AQP1 expression has an independent predictive value for outcome if stratified by age, tumour size, lymph node status, histological grade and ER status. AQP1 expression in invasive breast carcinomas is associated with a basal-like phenotype and poor prognosis.

The aim of the present study was to evaluate the prognostic impact of basal and myoepithelial phenotype in breast carcinomas (BBC and MBC) in the palliative situation.Paraffin-embedded material from 244 primary breast carcinomas of patients with subsequent metastatic disease was stained immunohistochemically for CK 5/6, CK14, smooth-muscle actin, p63, estrogen receptor and progesterone receptor. BBC was defined as positive for CK5/6 and/or CK14 and MBC as positive for SMA and/or p63. Clinical and pathological data were available for all patients and follow-up data for 96.3% (range 5 days-151 months).Until the end of the follow-up period 90.2% of patients died and 6.1% are still alive. Of the tumours 28.7% could be classified as BBC and 8.2% as MBC. Kaplan Meier analysis revealed a trend for reduced survival after first diagnosis of metastasis (OASM) for BBC and MBC. Differences in survival were significant for BBC (log-rank =5.0; p=0.025), but not for MBC. CK5/6+ and CK14+ double positive tumours (n=18; 7.4%) were identified as a subgroup of BBC associated with reduced OASM (log-rank=8,6; p=0.003). This subgroup, but not BBC or MBC was an independent negative prognostic factor in a multivariate analysis including age, typing, tumour size, grading, axillary nodes, HR, Her2/neu, site of first metastasis and disease-free interval.The association of BBC and MBC with reduced OASM in metastatic breast carcinomas is not independent from established prognostic factors. CK5/6+ CK14+ double positive tumours may be a subgroup of BBC with particularly unfavourable outcome.

In the age of personalized medicine, and in addition to typing and grading, breast cancer pathologists are now also involved in determining biomarkers such as steroid hormone receptors and Her-2, which are of the utmost importance in adjuvant therapy. In order to assure quality of these biomarker assays, external proficiency testing has been implemented in Germany. Since 2002 trials have been conducted annually, with up to 180 participating laboratories. More than 85% of all participants achieved good results in clearly negative and positive cases seen in daily practice. If at all, discordant results were observed in the rarer low steroid-hormone receptor expressing tumors and Her-2 borderline cases (2+). Regular participation in interlaboratory testing leads to significantly improved immunohistochemical results, particularly in these problematic cases. Tissue microarrays (TMA) with 20-24 different breast cancer samples including cell lines meant that a huge number of pathologists were challenged with identical samples, providing the prerequisite for comparability. Participation is recommended for pathology departments involved in the service for breast units. The organizational frame work of the trials is described here. The confidence of cooperating disciplines in breast cancer biomarkers assessed by pathologists will be fostered by external proficiency testing as presented here.

Precise prognostication represents one of the essential but still unsolved challenges in breast cancer pathology. There is a striking discrepancy between the plethora of suggested markers that have proved useful in mono-centre retrospective studies, including molecular expression arrays and the only small number of parameters applied in clinical decision finding. When adjuvant therapy is considered clinicians still rely predominantly on traditional parameters like staging and hormonal receptor status. Another traditional marker which has proven its strength in mono-centre studies but is compromised by subjectivity and limited reproducibility is provided by grading. We have conducted a study on how traditional grading markers can be objectified and adapted to small amounts of tissue which have become custom with the wide-spread use ob needle biopsies. A modified grading scheme replacing mitosis counting by Ki-67 immunohistochemistry and nuclear pleomorphism by digital determination of nuclear size was applied to 346 cases of breast cancer with a median follow-up of 6 years in a tissue micro-array. A highly significant correlation with overall and disease-free survival could be established in this retrospective study although not more than 1.4 square millimeters of tissue were evaluated. When combined with nodal status and progesterone receptor evaluation a subgroup free of any relapse could be identified. It is concluded that standardized and objectified application of grading as a traditional tissue-based marker of prognosis can improve its impact considerably even in limited amounts of tissue.

Breast carcinoma is a rare disease in men. The incidence is 1 per cent of the incidence in women. Relative hyperestrogenemia and environmental factors seem to be important for the development of the disease. In recent years, germline mutations have been observed in male breast carcinoma patients in several genes, BRCA2, the androgene receptor gene and PTEN. Suspected genetic factors include the cell-cycle checkpoint kinase (CHEK)2 protein truncating mutation 1100delC that has been shown to confer a 10-fold increase of breast cancer risk in men. The c.1-34TC 5' promoter region polymorphism in cytochrome P450c17 (CYP17), a key enzyme in the biosynthesis of estrogen, has been associated with male breast cancer risk, hemochromatosis gene (HFE) mutations, the mismatch repair genes (hMSH2, hMLH1,hPMS1,hPMS2) and PTEN mutations (Cowden syndrome) are associated with male breast cancer. The majority of tumors is seen retromamillarly. Ductal carcinoma in situ comprises 5-10 % of all cancers. In case of invasive growth, 85-90 % are invasive ductal carcinomas (NOS), 2.5 % are papillary tumors; lobular cancers are exceptionally rare. About 3/4 of all cancers express estrogen and progesterone receptor with increasing positivity with increasing patient age. HER-2 / neu overexpression is seen in the same frequency as in female breast cancer. Poor prognostic factors are tumor size2 cm, poorly differentiated tumors, receptor negativity, axillary lymph node involvement and more than four affected nodes.

The recent discovery of the estrogen receptors alpha and beta (ERalpha, ERbeta) and the progesterone receptor (PR) in human prostate tissue offers new insights into the role of estrogens and their receptors in prostate cancer development and tumor progression. The differentiation compartment of the prostatic epithelium (secretory luminal cells) expresses high levels of ERbeta, while the ERalpha is restricted to the proliferation compartment (basal cells). In high grade prostatic intraepithelial neoplasia (HGPIN), ERalpha gene expression extends to luminal cells and thus may mediate cancerogenic effects of estrogens on the dysplastic epithelium. Conversely, the ERbeta is downregulated in HGPIN indicating that the chemopreventive effects of phytoestrogens mediated by the ERbeta are partially lost. Irrespective of grades and stages, prostate cancer retains high levels of the ERbeta which is partially lost in androgen-insensitive stages of the disease. In contrast with breast cancer, the presence of the ERalpha and the PR is a late event in prostate cancer progression. At least 30% of metastatic and androgen-insensitive tumors express high levels of the PR indicating that these tumors harbor a functional ERalpha. The antiestrogen Raloxifene has growth-inhibitory effects on androgen-insensitive prostate cancer cells in vitro and induces the apoptotic cell death in a dose-dependent fashion. These data provide a rational for clinical trials to study the efficiency of antiestrogens in the medical treatment of advanced prostate cancer.

The present review gives a survey on the differential expression of estrogen receptors alpha and beta (ERalpha, ERbeta) and the progesterone receptor (PR) in human prostate tissue and discusses their potential implications for normal and abnormal prostatic growth. The differentiation compartment of the prostatic epithelium (secretory luminal cells) expresses high levels of ERbeta, while the ERalpha is restricted to the proliferation compartment (basal cells). In high-grade prostatic intraepithelial neoplasia (HGPIN), ERalpha gene expression extends to luminal cells and thus may mediate cancerogenic effects of estrogens on the dysplastic epithelium. Conversely, the ERbeta is downregulated in HGPIN indicating that the chemopreventive effects of phytoestrogens mediated by the ERbeta are partially lost. Irrespective of grades and stages, prostate cancer retains high levels of the ERbeta, which is partially lost in androgen-insensitive stages of the disease. In contrast with breast cancer, the presence of the ERalpha and the progesterone receptor (PR) is a late event in prostate cancer progression. At least 30% of metastatic and androgen-insensitive tumors express high levels of the PR indicating that these tumors harbor a functional ERalpha. The antiestrogen raloxifene has growth-inhibitory effects on androgen-insensitive prostate cancer cells in vitro and induces apoptotic cell death in a dose-dependent fashion. These data provide a rationale for clinical trials to study the efficiency of antiestrogens in the medical treatment of advanced prostate cancer.

DNA ICM allows measurement of nuclear DNA content and genotypical grading of malignancy. The aim of this study was to prove the prognostic value of DNA parameter in comparison to established prognostic factors for DFS and OS.Cytological imprints of 177 unselected primary NNBC patients were subjected to ICM. ICM parameter 2cDI, 5cEE, 9cEE, DNA mean value, proliferation fraction (SG2M) and ploidy were investigated together with established parameter like pT-stages, histology, grading, hormone receptor status and patient age regarding DFS and OS. Univariate and multivariate analysis were performed.Univariate analysis revealed that except ploidy all ICM parameter and pT-stages, histology as well as grading were significant prognostic factors for DFS. However, only 2cDI and pT-stages were proved independent prognostic factors in multivariate analysis. Regarding OS 9cEE, histology and pT-stages were significant factors in univariate analysis. However, only 9cEE and pT-stages were found to be independent prognostic factors in multivariate analysis.DNA - ICM parameter 2cDI and 9cEE together with pT-stages were proved independent prognostic factors in NNBC patients.

Breast cancer is the most frequent gynecological tumor. The HER-2/neu oncogene may play a role in the prognosis and management of patients with breast cancer. In a retrospective study on 100 patients, we correlated the expression of this oncogene with the classic clinical and pathological factors. 32 % of patients exhibited overexpression of HER-2/neu. There was no significant correlation with classic parameters. This finding could indicate that HER-2/neu expression is a new independent prognostic factor. Prospective studies correlating HER-2/neu overexpression with prognosis might provide additional data.

We compared immunohistological examination of endometrium biopsy specimen with the results of the immunohistological examination of tumor specimen to analyse the valence of this preoperative examination according to the clinico-pathological findings and overall-survival.Between 1985 and 1995 193 women were treated of an endometrial carcinoma at the University hospital Mainz. In this group we evaluated 41 patients with enough preoperative endometrial biopsy material for a retrospective immunohistochemical analysis and complete follow-up data. The materials from diagnostic curettage were stained and analysed for oestrogen and progesterone receptor status and for MiB-1. The results were statistically analysed using Logrank-test for overall survival.The mean follow-up time was 49 months. We found a significant correlation between staining results of oestrogen (p-value = 0.0005) and progesterone (p-value=0.0003) receptor status with overall survival as well as for MiB-1 (p-value=0.05). The correlation of staining results between biopsy specimen results and tumor material from hysterectomy was 84-85 %.These well known prognostic factors are measurable on biopsy specimen material in same quality and high valence as on hysterectomy material.

The syndrome of the Rhinopathia gravidarum has been frequently discussed in the literature, but the etiology is yet unknown. An increase of oestrogen and progesterone concentration is said to contribute to the pathogenesis. The aim of this study was to localize estrogen (ER) and progesterone receptors (PgR) in the nasal mucosa of women and to compare the localization with the distribution of mast cells (MC). The patients' medical history was obtained with special emphasis on nasal symptoms during pregnancy, the menstrual cycle, or with the use of oral contraceptives.Immunohistochemistry (IHC) was performed on formalin-fixed paraffin sections (nasal mucosa, inferior turbinate of 40 women) with monoclonal antibodies against ER, PgR, and mast cell tryptase.PgR-positive cells were found in fibroblasts (nuclear staining). The cytoplasmic staining for ER in serous glands and excretory ducts and for PgR in the interstitium of glands is considered nonspecific. The pattern of the receptor distribution was different from the pattern seen in the MC-IHC. No significant statistical results were obtained comparing the patient's medical histories and the immunohistochemical findings.Our findings possibly indicate a direct influence of progesterone on fibroblasts and therefore on the consistency of the extracellular matrix. Additionally, estrogen and progesterone might cause rhinopathic symptoms indirectly by changing the concentration of neurotransmitters (e.g. substance P, NO) and their receptors.

To determine cytosol estrogen and progesterone receptor concentrations in the human lower uterine segment in different stages of cervical dilatation during parturition at term.Biopsy specimens of the lower uterine segment were obtained from 51 women undergoing non-elective cesarean section at term. The stage of cervical dilatation at the time of cesarean section was2 cm (N = 14), 2 to4 cm (N = 13), 4 to 6 cm (N = 11) or6 cm (N = 13). The cytosolic estrogen and progesterone receptor concentrations were determined by enzyme immunoassays.Median estrogen receptor concentrations at2 cm and at 2-4 cm cervical dilatation were 2.12 fmol/mg protein and 2.03 fmol/mg protein, respectively. After a significant drop at 4-6 cm cervical dilatation (median: 1.08 fmol/mg protein), estrogen receptor concentrations raised again at6 cm cervical dilatation (median: 2.00 fmol/mg protein). Median progesterone receptor concentration was 84.7 fmol/mg protein at2 cm cervical dilatation, diminished significantly at 2-4 cm cervical dilatation (36.6 fmol/mg protein) and increased at further cervical dilatation (4-6 cm: 75.7 fmol/mg protein;6 cm: 83.7 fmol/mg protein).These data suggest that predominantly a decrease in cytosolic concentration of the progesterone receptor at the beginning of the active phase of first stage labor may play a crucial role in the hormonal control of cervical dilatation during parturition at term.

In which way is the biochemical analysis of fine needle biopsy comparable to the biochemical analysis of conventional surgical biopsy samples in the examination of prognosis factors in mammary carcinomas.Conventional surgical biopsy and fine needle biopsy were performed on 63 mammary carcinomas. The results from the biochemical analysis of tissue samples, from each form of biopsy, with respect to estradiol and progesterone receptor, UPA and PAI-1, as well as Kathepsin D and the EGF receptor, were compared and statistically analyzed.When compared to conventional tissue biopsy samples, the sensitivity and specificity of the measured prognosis factors in fine needle biopsy tissue were variable for each parameter, but fell within the statistically safe margin of 86 to 100%.The biochemical analysis of the prognosis factors found in fine needle biopsy samples showed that fine needle biopsy is a viable alternative to intraoperative conventional surgical biopsy.

The estrogen- (ER) and progesterone receptors (PR) of 27 pre- and 33 postmenopausal primary breast carcinomas with 320 axillary lymphonodal metastases were investigated in formalin-fixed paraffin-embedded tissue.Special interest was devoted to the comparison of the receptor equipment between the axillary lymphonodal metastases and the appertained primary carcinoma. ER-antibody D5 and PR-antibody NCL-PGR were used for investigation.ER-positive carcinomas of premenopausal women and ER-respectively PR-positive carcinomas of postmenopausal women corresponded significantly more frequent to receptor-positive lymphonodal metastases. Carcinomas with receptor-positive metastases were mostly ER-positive and PR-negative. About all receptor-positive metastases had the same combination of receptors. In cases of high numbers of lymphonodal metastases these were in general more often receptor-negative. Respectively, the receptor-positive metastases numbered lower than the receptor-negative. Immunohistochemical receptor-negative primary carcinomas can inherit receptor-positive lymphonodal metastases.Immunohistochemical investigations render it possible to determine ERs and PRs not only in primary carcinomas but in lymphonodal metastases, too. Eventually the prognostic factors "ER" and "PR" will be used more often in the determination of therapeutic decisions.

Analysis of estrogen and progesterone receptor (ER, PR) status was performed in pre-, peri- and postmenopausal women at the time of surgery in 60 women with breast cancer and 19 women with benign breast disease by comparative use of the dextrose coated charcoal method and the immunohistochemical assay (peroxidase-antiperoxidase technique). In premenopausal women we furthermore differentiated depending on the menstrual cycle at the time of surgery. The retrospective study shows sufficiently consistent results in both analytical procedures. There was no difference in the expression of ER and PR in pre- and postmenopausal women, furthermore, ER and PR expression was not significantly different during the follicular phase compared to luteal phase.

The ovarian steroid hormones estradiol and progesterone exert their effect by interacting with their intracellular receptors, which, after ligand binding translocate to the nucleus and bind to the promoter regions of target genes. The consequence is a change in the transcription rate of the target genes, followed by a change in production of the corresponding proteins. Target genes of the sexual steroid hormones include cytokines and growth factors, among them CSF-1, TGF-beta and LIF. The rhythm and activity of steroidogenesis, receptor modulation and transcription are reflected by cycle-specific proliferation and differentiation processes in the endometrium. Quantitative and/or qualitative molecular endocrinology is of increasing interest for better definition of morphological changes, although, as yet, the pathological laboratory test is of much less practical consequence than a suspicious vaginal sonography. In spite of the high standard of ultrasound techniques, however, most cases with slightly increased endometrial thickness show histologically benign changes of the endometrium rather than endometrial precancer or cancer. This is especially true for perimenopausal women with no other clinical findings. Yet, the cancer risk is increased in women under tamoxifen therapy. Hence, as a rule, these cases, when endometrial thickness exceeds 5 mm, need a diagnostic biopsy or abrasio.

In addition to classical morphological prognosis factors of breast carcinoma (pTNM stage, tumor grading, histological typing), many other immunohistochemical markers of different prognostic value exist.--The comparative estrogen (ER) and progesterone receptor (PR) analysis of normal and pathological breast tissue showed a gradually inverse biological correlation between the decrease of ER+PR+ and the increase of ER-PR-frequency from benign breast changes to noninvasive and invasive breast carcinomas. In benign breast epithelium, ER+PR+ and ER-PR+ might be regarded as low-risk phenotype, whereas ER+PR- and ER-PR- could be estimated as high-risk phenotype in view of a later dedifferentiation and possible malignization.--During carcinogenesis, the initial loss of epithelial growth factor receptor (EGF-R) as well as its later neoexpression could be regarded as a progression maker.--The proliferation rate (Ki67) in breast cancer significantly correlates with increasing grading and apoptosis rate, whereas the expression of bcl-2-protooncogene is inverse to increasing grading. As for the prognostic value of the single factors, it is supposed that they mostly might represent "one piece of a larger puzzle" [13].

To reduce the need for excisional biopsies in the diagnosis of breast masses, the accuracy of core needle biopsy (CNB) was determined in a university hospital setting. 150 consecutive women with solitary palpable breast masses underwent CNB over a 2-year period. Histological diagnosis was established, and in the case of cancer the type, grade and estrogen and progesterone receptors were determined. CNB findings were compared with those independently obtained from the subsequently excised lesions. There were 103 malignant and 47 benign lesions. CNB diagnosed 136 lesions (90.7%) correctly. Fourteen biopsies were inconclusive. Histological type was correct in all cases and grading in 83.5%. Correct hormone receptor status was obtained in 97.1% of cases for estrogen and 91.3% for progesterone. Diagnosis of histological type, grading, and hormone receptors obtained from CNB material is a safe way to analyze palpable breast lesions and therefore a useful tool to select patients for preoperative treatment.

Prostate specific antigen is a highly specific marker of prostatic tissue. Recent studies have shown, that it is present in several other human tissues, tumors and fluids. PSA has been identified as a serine protease and member of the kallikrein family of enzymes. In our study PSA concentration was measured in 97 cytosols of breast cancer tissues and 14 samples, prepared from human endometrium. Cytosols were analysed also for steroid hormone receptors, EGF-receptor, Cathepsin D and pS-2 protein. PSA was found in 84.5% of breast cancer tissues and in 12 endometrium samples. High concentration of PSA were associated with high pS-2 protein levels. No correlation was found between the concentration of steroid hormone receptors and PSA in our material. The results suggest, that PSA in cytosol of human breast cancer and endometrial tissues may be an additional new prognostic indicator.

Breast cancer is the most frequent malignant tumor in women, whereas it is rare in men. In our own case series the ratio is 175:1. The present paper deals with an evaluation of clinical and morphological findings from a series of 54 de novo male breast cancers observed in our institution from 1978 to 1996 and a comparative discussion of 528 female breast cancers from the same geographic area. We should like to focus on the following observations: At the time of histopathological diagnosis, male patients with breast cancer were on average 67 (34-87) years old and thus 5 years older than women. Below the age of 40, breast cancer is very rare in men. The lag time between first symptoms and surgery was on average 42 weeks, i.e. twice as long as in women. In the vast majority of cases palpation of a retromamillary nodule was the leading diagnostic symptom. Mamillary secretion appeared to be an early symptom with favorable relation to prognosis by tumor size whereas diffuse breast swelling was an unfavorable late symptom. Bilateral carcinoma and double cancer (breast and prostatic cancer) was observed in one case each. Three patients (3/51 = 6%) had a positive family history (breast cancer in 1st and 2nd degree relatives). The average invasive tumor size was nearly identical with 23 mm (s11.02) in men and 25 mm (s13.48) in women. Men presented more frequently with regional lymph node metastases (53% versus 45%), which tended to develop earlier. pT4 cancers were twice as frequent in men compared to women. In situ cancers were found in 2% (1/54) in men and 4% in women. Similar to females, male breast cancers are predominantly of ductal histological type (NOS-cancers), classical lobular carcinoma with LCIS-components were not observed; special forms (tubular, papillary, mucinous) are slightly more common in men. When reviewing our series, need for revision of the origin of tumor was not found in any of the cases. Metastases of prostatic cancer were never misinterpreted as primary breast cancer. In case of isolated NSE-reaction, cancers with carinoid differentiation pattern are to be found in nearly every second tumor. However, when multiple markers were used (chromogranin A or synaptophysin) only 10% displayed such pattern, which corresponded to a positive hormone receptor status in each case. Quantitative (enzyme immunoassay) and semiquantitative (immunohistochemistry) analysis of steroid hormone receptor status was positive in 86% of 35 cases in men and in 75% in women. In contrast to female breast cancer, hormone status proved to be independent of age in males. The average levels of estrogen and progesterone were higher in men. Overlapping results were found only when cases were compared with postmenopausal women. The Nottingham prognostic index, a product of primary tumor size, axillary lymph node status and grading allows an approximative estimate of the course of the disease; its predictive value is higher than that of isolated tumor markers.

Much is unknown about the effects of estrogen's on the mammary gland in postmenopausal women today. In a recent study of estrogenmonotherapy 28 adult, surgically postmenopausal female monkeys (Macaca fascicularis) were treated continuously with estradiol or were given only a diet (control group). After 6 months serum levels of estradiol and progesterone, morphometrical, histopathological and immunohistochemical measurements of the mammary gland were performed. In monkeys receiving estradiol the mammary epithel thickness and the mammary epithelial area (as percentage of total breast area) increased. Estradiol induced mammary gland hyperplasia, but we did not see any atypical hyperplasia. Estradiol and progesterone receptors staining in mammary ducts and lobuli increased (not significant). Estradiol induced a mammary gland proliferation (not significant) shown as increased staining for PCNA and Ki67.

In a subset of 183 primarily operative treated patients of 300 patients with endometrial carcinoma an analysis of histological tumor type (n = 142), myometrial invasion (n = 115), stage (n = 114), immunohistochemically detected steroid receptor status, histologic grading (n = 152) and growth fraction, detected by immunohistochemical determination of antibody Ki-S1 (n = 130), was performed. The mean follow up was 9.1 years. By univariate analysis, age, myometrial invasion (= 3/3 mm), expression of steroid receptor, FIGO-stage, histologic grading and growth fraction were found to influence the overall survival rate significantly. Cox multivariate regression showed age, FIGO-stage and growth fraction to be independent predictors of overall survival. With respect to survival univariate analysis revealed progesterone receptor status, FIGO-stage, histologic grading and growth fraction as prognostic factors. By multivariate analysis FIGO-stage, histologic grading and growth fraction were found to be independent prognostic factors for survival. Multivariate and univariate analysis exhibited FIGO-stage, histologic grading and growth fraction rate to be independent predictors of a disease-free survival. Immunohistochemically detected growth fraction seems to be useful as an additional prognostic factor in endometrial cancer.

A retrospective study was performed to follow up the course of the disease in 137 female premenopausal and postmenopausal patients in whom local recurrence of carcinoma of the breast had occurred. Particular attention was given to the dependence of the recurrence-free interval on the tumorobiological parameters of the primary tumour. In 23% of the cases the local recurrence was an expression of generalisation of the tumour with simultaneous occurrence of distant metastases. The average recurrence-free interval was four years, but more than half of the recurrences were seen during the first two postoperative years. For the following parameters we found a statistically significant correlation with the recurrence-free interval: size of the primary tumour (p = 0.0003), the nodal status (p = 0.0006) and in this connection also the number of the metastatically involved lymphatic node level (p = 0.00001). There was also a significant correlation between the duration of the recurrence-free interval and the immunohistochemical oestrogen and progesterone receptor status (p = 0.0005) and the growth fraction (p = 0.0106) determined with the monoclonal antibody Ki67. However, although there was no correlation between recurrence-free survival and the kind of surgical primary therapy that had been employed, adjuvant therapy did exercise a decisive influence: there was significant later incidence of local recurrences (p = 0.00001) subsequent to adjuvant radiotherapy.

We tested whether immunohistochemical detection of oestrogen and progesterone receptor (ER, PR), the oestrogen-dependent protein pS2, the growth hormone receptors p 185neu and EGF-R, the tumour suppressor protein p53, the tissue proteases Cathepsin D and Urokinase, and the proliferation marker PCNA are of prognostic relevance in breast cancer patients.Expression of the proteins listed above was evaluated in formalin-fixed and paraffin-embedded sections of 311 primary breast cancer specimens using modified Avidin-Biotin-Complex methods. Results were correlated to clinical and morphological parameters (age, menopausal status, nodal status, tumour size, tumour grade), and clinical course of disease (complete follow-up in 301 women, median observation time 62 months) utilising univariate and multivariate statistical analyses.If univariate analyses and multivariate regression analyses according to the Cox-model were applied, only Cathepsin D correlated to an elevated risk for recurrence in nodally negative patients (n = 135). In nodally positive women (n = 161), increasing tumour size, tumour grade, lack of ER and PR, expression of p185neu, p53, and PCNA indicated a significantly increased relative risk.Immunohistochemistry allows the detection of parameters which may indicate prognosis in subgroup of breast cancer patients.

A 56-year-old women who had undergone hysterectomy 15 years ago was found to have pulmonary leiomyomatosis. The occurrence of hormone receptors shows the influence of the ovary and of hormone-replacement-therapy to these tumors. In our case immunoperoxidase techniques indicate the expression of progesterone receptors.

In 216 breast cancer patients, the prognostic value of current biological factors (c-erbB-2, EGF-receptor, p53, PCNA-proliferative fraction) was compared with that of conventionally histomorphologic features (histologic type, histologic grade, tumour size, hormonal receptor status). After a 66(6 - 109) months' median follow-up survival was significantly correlated with histological grade (p = 0.014) and PCNA-proliferative activity (p = 0.015). The prognostic influence of oestrogen receptor (ER)- and progesteron receptor (PR-)status achieved borderline significance (ER/p = 0.07; PR/p = 0.05). Neither c-erbB-2, EGF-R, p53 nor any of the other factors showed any correlation to survival. In the multivariate analysis, histological grade was revealed as the only independent prognostic factor. The prognostic value of PCNA was second to histological grade and if grade was excluded from the analysis, PCNA-expression became the only independent factor. Thus, in individual cases the PCNA-proliferative fraction could help the clinician to decide on the therapy.

The synthesis of pS2 protein is induced through estrogen-dependent transcription of the pS2 gene. The presence of the pS2 protein in breast cancer is thought to be as valuable as receptor status, or even more so, in predicting the response to hormonal therapy. Furthermore, pS2 appears to be a prognostic factor for primary breast cancer. In 162 cases of primary breast cancer, pS2 was tested by immunohistochemical procedures on formalin-fixed and paraffin-embedded tissues. Staining was evaluated semi-quantitatively using an immunoreactive score (IRS). The concentrations of pS2 in tumor cytosol were determined using an immunoradiometric assay. Positive staining for pS2 (IRSor = 2) was seen in 27% of the tumors. Comparison of immunohistochemical and biochemical detection (26% of tumors had pS2 cytosol concentrations above the cut-off value of 26 ng/mg cell protein) revealed an 81% concordance rate (r = 0.76; P0.0001). Univariate analysis showed no significant correlation of immunohistochemical pS2 detection and age or menopausal status of patients, tumor size, tumor grade or nodal status. However, the immunohistochemical pS2 status correlated significantly with the immunohistochemical detection of the estrogen (ER; P0.001) and progesterone receptor status (PR; P0.0001). pS2-positive tumors were ER-positive in 66% of cases and PR-positive in 73%; 89% of pS2-positive tumors were positive for ER and/or PR. The incidence of immunohistochemical pS2 detection was 41% in the group of steroid receptor positive carcinomas (ER- and/or PR-positive) in contrast to 7% in steroid receptor negative tumors (ER- and PR-negative).

For evaluation of the hormone receptor status in breast cancer tissues two methods are mainly used: immunohistochemical detection by monoclonal antibodies on frozen sections (ER-ICA, PgR-ICA) and the biochemical radioligand-binding assay (DCC) of fresh tissue. Using new antibodies makes it possible to evaluate the estrogen and progesterone receptor status in formalin-fixed and paraffin-embedded tissue. In the present retrospective study, tissues from 223 primary breast carcinomas or breast carcinoma recurrences were re-evaluated with the three methods mentioned above and the results were compared. We used antibody 1D5.26 reacting with the estrogen receptor and mPR1 specific for the progesterone receptor in paraffin-embedded tissue. The agreement of positive and negative cases between these two immunohistochemical procedures was 97.8% for the estrogen receptor and 85.7% for the progesterone receptor. Comparison of immunohistochemistry on paraffin-embedded tissue and biochemical evaluation showed an agreement of 74.7% for the estrogen receptor and 68.7% for the progesterone receptor. These results are comparable to the correspondence between ER-ICA and PgR-ICA and the DCC method. This study proves that the prognostically and therapeutically important hormone receptors can be reliably determined in formalin-fixed and paraffin-embedded tissues. These results are not only important for the evaluation of hormone receptors of a small breast carcinoma that is not found in the frozen section, but for the considerable difference in costs among the different methods.

In 250 patients with node-negative breast cancer and no systemic adjuvant therapy the impact on the prognosis of the variables age, histological tumour type, tumour size, histological grade, receptor status and localisation of the tumour within the breast, was studied. Patients were followed over a mean period of 60 (range 7-164) months. In a subset of 124 cases additional examination of the growth fraction rate, detected by immunohistochemical determination of antibody Ki-67 and semiquantitative measurement of the stained tumour cell nuclei was performed. In 43 cases, measurement of S-phase fraction by flow cytometry was also performed. By univariate analysis, the histological tumour type (ductal/non-ductal), histological grade and growth fraction rate (= 20%/20% tumour cell nuclei stained by antibody Ki-67) were found to exert a significant influence on distant disease-free and overall survival. Cox' multivariate regression exhibited histological tumour type and growth fraction rate to be independent predictors of distant disease-free and overall survival. Additionally, age was found to be an independent variable of distant disease-free survival. Measurement of growth fraction rate by immunohistochemical detection of Ki-67 antigen is a fairly simple and easily applicable procedure. It should be discussed whether a growth fraction rate of more than 20% could be an indication for adjuvant chemotherapy in patients with node-negative breast cancer.

The occurrence of the p 53 gene mutation in breast carcinoma tumour cells, leads to the accumulation of mutant p 53 protein types, whose consequence is the loss of the negative regulation normally exercised by the p 53 gene, which is considered to act as a tumour suppressor. It is possible to demonstrate the presence of mutant p 53 protein types in tumour cell nuclei by applying immunohistochemical procedures to paraffin sections (Clon DO 1, Dianova). We tested 482 primary breast carcinomas for the presence of these proteins, and positive immunohistochemical findings for mutant p 53 proteins were recorded in 21.6% of the cases. In another 14.3% of these breast carcinomas, less than 10% of the tumour cells exhibited positive staining. In the other 64.1% of cases, the immunohistochemical findings for p 53 proteins were entirely negative. Independent of the immunohistochemical staining results, we performed a retrospective analysis of the disease course of this group of primary breast carcinomas: it emerged, that p-53-positive breast carcinomas had a significantly less favourable prognosis as compared to primary tumours, which were negative or weakly positive for this protein group. The accumulation of p 53 proteins in tumour cell nuclei is correlated with negative oestrogen- and progesterone-receptor status, as well as with the degree of proliferation exhibited by the breast carcinoma. Such accumulation is, in contrast, unaffected by the tumour stage, its histological grading, menopausal status, and the overexpression of c-erb B2.(ABSTRACT TRUNCATED AT 250 WORDS)

Analyses of the level of expression of the epidermal growth factor receptor (EGF-R) of breast cancer tumours may add independent information about the prognosis for individual patients. Furthermore, the use of monoclonal antibodies directed against EGF-R as therapeutic tools (e.g., Mab 425) requires a reliable evaluation of the individual EGF-R content. Various analytical methods have been published, including (1) biochemical detectonn of EGF-R by a radiolabelled physiological ligand, (125I)EGF, (2) enzymatic analyses of EGF-R content (IEMA), (3) immunological analyses of EGF-R content with a monoclonal antibody (ELISA), and (4) immunohistochemical EGF-R detection. Studies with immunohistochemical analyses of EGF-R overexpression in formalin-fixed, paraffin-embedded tumour samples are rare. In a retrospective study, we examined the clinical data from 142 patients and the EGF-R expression in their formalin-fixed, paraffin-embedded tumour samples. The average follow-up was 69 months. EGF-R expression was compared to oestrogen (ER) and progesterone (PgR) receptor expression, histological grade, tumour size, lymph node metastases and menopause. 52 of 142 tumours were EGF-R positive. EGF-R overexpression correlated with high tumour grade, large tumours and elevated numbers of lymph node metastases. There was no significant correlation between ER or PgR and EGF-R expression. Determination of EGF-R overexpression revealed no significant difference in disease-free interval (DFI) or overall survival (OS). In this study, the determination of EGF-R in formalin-fixed, paraffin-embedded tumour samples proved feasible. Unfortunately, this did not add any additional information concerning DFI or OS.

Oestrogen receptors were demonstrated immunohistochemically in 120 breast cancer cases; in 90 cases, progesterone receptors were additionally assessed. Immunohistochemical staining was evaluated by the so-called "immuno-reactive score" and quantified densitometrically by a method of computer-assisted image analysis. The measuring method allowed an objective evaluation of the portion of receptor-positive cells, the mean optical density and the distribution pattern of receptor concentrations within receptor-positive nuclei. Image analysis was compared with the semiquantitative evaluation by IRS. In 29 out of 58 weakly stained sections, which were scored as receptor-negative, receptor-positive cells could be demonstrated by image analysis because of the definition of an objective cut-off level for specific staining. Furthermore, three different patterns of distribution of receptor concentration could be distinguished: Type 0: receptor-negative carcinomas Type 1: homogeneous receptor expression within receptor-positive cells Type 2: heterogeneous receptor expression with high receptor concentrations in single cells. Type 2 patterns were almost exclusively found in postmenopausal patients, a dependence of expression pattern from grading was not demonstrated. These distribution patterns were found in the same manner in the expression analysis of progesterone receptor. With immunohistochemical staining only 45% of ER-negative carcinomas expressed PR, but 74% of ER-positive carcinomas. When ER was expressed heterogeneously (Type 2) PR was expressed in the same way in 62% of the cases. Beneath the exact determination of the portion of receptor-positive cells the analysis of the pattern of distribution is only possible by image analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

The concentration of total cathepsin D in tumor cytosol was measured in 300 patients with primary breast cancer treated at the Women's University Hospital in Würzburg between 10/86 and 9/92. Patients were followed for a median of 28 months. The level of cathepsin D was correlated with estrogen receptor status and tumor size but seemed to be independent of progesterone receptor status, histological grading, patient's age, axillary lymph node involvement and primary distant metastases. Overall survival, disease-free survival and metastases-free survival did not differ between patients with cathepsin D-levels above the median value of 47 pmol/mg of protein and patients with cathepsin D-concentration below 47 pmol/mg. Patients with node-negative disease and low cathepsin D-levels (or = 47 pmol/mg) had a longer disease-free survival than those with cathepsin D-concentration47 pmol/mg (p0.05). Our findings could not confirm cathepsin D as a useful additional prognostic marker in all breast cancer patients. In the low-risk collective the measurement of total cathepsin D may be significant by isolating subgroups with a poorer prognosis who might benefit from adjuvant therapy.

Wet autoclaving is a simple, reliable and time-effective method for antigen retrieval in routinely processed archival material. Both routine diagnostic (e.g., oestrogen and progesterone receptors, cytoskeletal proteins) and research antibodies (e.g. various p53 antibodies, mdm-2, bcl-2, MIB-1) are reported to demonstrate its application. We autoclaving may allow successful application of antibodies in paraffin-embedded tissues designed for use on frozen sections. The technique has the potential to reliably handle up to 200 sections at a time, without evidence of any significant damage to the sections or nuclear morphology.

The prognostic significance of the lysosomal protease cathepsin D in breast cancer was evaluated in a retrospective study. Cathepsin D was measured in 346 deep-frozen (-70 degrees C) cytosol specimens of primary breast carcinomas (1982-1990). Among the established prognostic factors, only axillary lymph node involvement correlated with the expression of cathepsin D (40/60 pmol/mg) (p = 0.04-0.05). Univariate analyses of disease-free survival (DFS) and overall survival (OS) showed, that the expression of cathepsin D had no effect on the prognosis either in the whole population of breast cancer patients during long-term follow-up (n = 302; median observation time 51 months) or in the group of women with positive lymph nodes (n = 157; 46 months). However, within the group of N0 patients (n = 145; 57 months), high cathepsin D levels were associated with an unfavourable OS, but this relationship was statistically insignificant (p = 0.08-0.13). A similar influence of cathepsin D on DFS could not be demonstrated. Compared to tumour size, grading and receptor status in multivariate analysis, cathepsin D was a more indicative, but finally insignificant prognostic factor for OS. According to these results, cathepsin D may contribute only in combination with other prognostic factors to identify those 20-30% of node-negative patients with unfavourable prognosis, who may benefit from adjuvant therapy.