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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 15  |  Issue : 2  |  Page : 202-208

Comparison of various scoring systems by immunohistochemistry for evaluating hormone receptors (Estrogen receptor and progesterone receptor) in carcinoma of breast


Department of Pathology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi(Meghe), Wardha, Maharashtra, India

Date of Submission13-Jan-2020
Date of Decision30-Jan-2020
Date of Acceptance10-Mar-2020
Date of Web Publication21-Dec-2020

Correspondence Address:
Dr. Prachi Dileep Rai
Post-Graduate Student, Dept. of Pathology, Jawaharlal Nehru Medical College, DMIMS(DU), Sawangi(M), Wardha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_7_20

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  Abstract 


Background: Immunohistochemistry (IHC) is used to assess hormone receptor status evaluating hormone receptors (estrogen receptor and progesterone receptor [ER/PR]) in infiltrating ductal carcinoma of breast and determined by scoring systems: Allred (quick) and H scoring system. The present study intended to evaluate the values of these score systems in terms of correlation with Bloom-Richardson grading system of breast carcinoma. Aim: To compare Allred and H scoring systems for evaluating hormone receptors in carcinoma of breast by IHC with modified Bloom-Richardson's grading system. Objective: (1) To confirm and classify histopathology of breast tissue by routine hematoxylin and eosin staining. (2) To obtain grading by Bloom-Richardson grading system. (3) To evaluate breast carcinoma by IHC and assess by Allred and H scoring system of hormone receptors. (4) To compare these scoring systems with Bloom-Richardson grading system. Study Design: Observational, cross-sectional, and comparative. Materials and Methods: BR grade and HR status of 65 surgically resected specimens of carcinoma breast were determined by routine histopathological examination and IHC. Allred and H scoring systems were employed to evaluate HR status. Statistical Analysis: Using Chi-square test and P < 0.05 considered as level of significance. Results: The common grade was Grade II accounting to 73.85% followed by Grade I and Grade III, i.e., 16.92% and 9.23%, respectively. Immunohistochemical analysis was done and most cases belonged to ER(−)/PR(−) category, i.e., 30 cases (46.16%). Allred and H scores were analyzed and compared these scores with Bloom-Richardson Grading system. According to Pearson's correlation matrix, it was observed that a statistical significant correlation was found between Allred and H score system and had an equivalent value for ER and PR (P < 0.0001). Conclusion: The present study had shown that there was no difference between Allred and H score system and had a good correlation with BR grading system as both being semi-quantitative methods and can be practiced regularly for assessment of HR.

Keywords: Carcinoma of breast, hormone receptors (estrogen receptor and progesterone receptor), immunohistochemistry, scoring systems of carcinoma breast


How to cite this article:
Rai PD, Vagha S, Shukla S, Bhake A. Comparison of various scoring systems by immunohistochemistry for evaluating hormone receptors (Estrogen receptor and progesterone receptor) in carcinoma of breast. J Datta Meghe Inst Med Sci Univ 2020;15:202-8

How to cite this URL:
Rai PD, Vagha S, Shukla S, Bhake A. Comparison of various scoring systems by immunohistochemistry for evaluating hormone receptors (Estrogen receptor and progesterone receptor) in carcinoma of breast. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Jan 19];15:202-8. Available from: http://www.journaldmims.com/text.asp?2020/15/2/202/304268




  Introduction Top


Cancer incidence and prevalence are rapidly growing worldwide.[1],[2] Breast cancer is also the most common malignancy in women around the world which comprised a heterogeneous group of patients. According to the GLOBOCAN 2012, it is accounting for 25.1% of all cancers and includes 1.7 million new cases per year. The incidence rate of breast cancer ranges from 19.4/100,000 people in East Africa to 89.7/100,000 in West Europe (WHO, 2015).

Breast cancer has ranked number one cancer among Indian females as well and is facing a challenge due to increased incidence by 11.54% and mortality by 13.82% due to a breast cancer during 2008–2012.[3],[4]

Recently, new categorizations of invasive carcinoma (not otherwise specified) are established which depends on gene expression and molecular subtypes which provides an information of different therapeutic modalities.

Nowadays, histopathological grading of breast cancer is done using Modified Bloom-Richardson grading system [BR Grading], which has been a gold standard not only for the diagnosis of breast cancer but also has played a very important role as traditional prognostic factor.[5]

The molecular subtypes have been evaluated using biological markers that includes the presence or absence of hormone receptors that is estrogen receptor (ER) and progesterone receptor (PR).[6]

Immunohistochemical evaluations of hormone receptors (ER and PR) are based on two main features that are the proportion of stained cells and the intensity of the staining. Hence, for evaluating these two features, scoring systems such as Allred (quick) scoring system and histochemical (H) scoring system have been practiced at different centers.[7],[8]

The study was undertaken to compare Allred (quick) score and H score system for evaluating hormone receptors by immunohistochemistry (IHC) and correlated with Bloom-Richardson grading system of carcinoma of breast.[8],[9],[10]


  Materials and Methods Top


The present study was conducted in the histopathology and IHC section of Department of Pathology, JNMC, DMIMS (DU), Sawangi (M), Wardha, Maharashtra, from August 1, 2017, to July 31, 2019, which was an observational, cross-sectional, and comparative.

Sample size: 65 cases:[9]

  • Inclusion criteria: IDC (NOS type) diagnosed female patients of all ages and had undergone simple mastectomy, MRM, lumpectomy, Tru-cut biopsy specimen
  • Exclusion criteria: Neoadjuvant chemotherapy-received patients, male patients, recurrent cases.


Sections from specimen were taken and tissue processing was done followed by routine hematoxylin and eosin staining on histopathology. Scoring was done by Modified Bloom-Richardson grading system.

Sections from representative area of tumor mass were subjected to IHC by DAKO kit for ER and PR status and scores were calculated by Allred (quick) and H scoring system. Then, derived scores were compared with the Modified Bloom-Richardson scoring system.

Controls for estrogen receptor and progesterone receptor

External positive controls: Cases of IDC (NOS type) breast carcinoma. Internal positive controls: Normal or nonneoplastic mammary epithelium.

Allred (quick) scoring system for estrogen receptor and progesterone receptor

It is a semi-quantitative system. Both the proportion score and intensity score (IS) are summed up and total score (TS) is derived. A score of 0–1 is regarded as negative while 2–8 is considered as positive [Table 1] and [Figure 1].
Table 1: Allred (Quick) scoring system for estrogen receptor and progesterone receptor[10]

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Figure 1: Section stained with immunohistochemical stain (ER) shows 11%–33% nuclei suggesting proportion score 3 shows intermediate staining intensity suggesting intensity score 2 at high-power view (×40). So, Allred Score: 5 and H score: 60%

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H (Histochemical) scoring system for estrogen receptor and progesterone receptor

It is also a semi-quantitative scoring system for hormone receptors incorporating both intensity of cells and percentage of distribution of specific staining as described by McCarthy Jr. et al. It is based on a predominant staining intensity. An IS can be measured as follows: Score 0: no staining; score 1: weak staining; Score 2: moderate staining; and Score 3: Strong staining.[12],[13]

Therefore, for this H score, need to evaluate both intensity and percentage of distribution of positively stained tumor cell of respective intensity [Table 2] and [Figure 2].
Table 2: Percentage of positively stained tumor cells (immunohistochemical quantification)

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Figure 2: Section stained with immunohistochemical stain (ER) shows 67%–100% nuclei suggesting proportion score 5 shows strong staining intensity suggesting intensity score 3 at high-power view (×40). Allred score: 8 and H score: 300%

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The evaluations are recorded as percentages of positively stained tumor cells in each of the intensity categories.[11]

Then, the final score should be taken from the summation of percentage of cells at each intensity level using following formula:

Total score: ∑ (1× [% cells with weak staining] +2 × [% cells with moderate staining] +3× [% cells with strong staining])

The final score ranging from 0 to 300. Score 0–50: Negative, score 51–100: Low positive, score 101–200: Moderate positive, score 201–300: Strong positive.

Ethics

The study was undertaken with the approval of institutional ethics committee. Informed consent was taken from all the patients who were included in the study.

Statistics

Statistical analysis was done using inferential and descriptive statistics with the Chi-square test and software using for analysis were SPSS 24.0 version (Chicago, Illinois, USA) and GraphPad Prism 7.0 version (San Diego, CA). P < 0.05 was considered as level of significance.

Ethical Approval

Ethical approval for this study (DMIMS(DU)/IEC/2017-18/6719) was provided by the Ethical Committee of Datta Meghe Institute of Medical Sciences (Deemed to be University) on 04/10/17.


  Results Top


In the present study, out of 65 diagnosed cases of infiltrating ductal carcinoma (NOS type), 49 specimens were of MRM, 9 Tru-cut Biopsy, 6 mastectomy specimens, and 1 lumpectomy specimen.

The results of histopathology and IHC were carefully noted, interpreted, and recorded in tabular form.

In the present study, the youngest patient presented at 21 years of age and the oldest patient was 80 years of age with the mean of 53.32 years (SD 12.95). Out of 65 cases, the most common grade was Grade II accounting to 48 cases (73.85%) followed by Grade I and Grade III, i.e., 11 cases (16.92%) and 6 cases (9.23%), respectively.

Hormone receptor status by IHC was obtained and most of the cases belonged to the ER(−)/PR(−) category, i.e., 30 cases (46.16%) followed by ER(+)/PR(+) constituting 23 cases (35.38%) and ER(+)/PR(−) having 12 cases (18.46%). A statistically significant inverse correlation was observed between grading of tumor mass and ER and PR receptor expression.

If we analyzed cases by Allred score system, 10 out of 11 of cases belonged to Grade I represent high ER and PR expression while all 06 cases belonged to Grade III represent low ER and PR expression. The statistical analysis was significant with a P = 0.0042 and 0.005 for ER and PR, respectively [Table 3] and [Figure 3].
Table 3: Association of division of Allred Score System of estrogen receptor and progesterone receptor with BR grade of tumor mass

Click here to view
Figure 3: Section stained with immunohistochemical stain (PR) shows 11%–33% nuclei staining suggesting proportion score 3 shows weak staining intensity suggesting intensity score 1 at high-power view (×40). Allred score: 4 and H score: 30%

Click here to view


While analyzing same cases by H score system, 9 cases of ER and 6 cases of PR out of 11 cases belonged to Grade I represent high ER expression while all 06 cases belonged to Grade III represent low ER and PR expression. The statistical analysis was significant with a P = 0.017 and 0.045 for ER and PR, respectively [Table 4] and [Figure 4].
Table 4: Association of division of H score system of estrogen receptor and progesterone receptor with BR grading of tumor mass of carcinoma of breast

Click here to view
Figure 4: Section stained with immunohistochemical stain (PR) showing 67%–100% nuclei staining suggesting proportion score 5 shows intermediate staining intensity suggesting intensity score 2 at high-power view (×40). Allred score: 7 and H score: 180% of PR at high-power view (×40)

Click here to view


That means, lower grade of tumor showed more positive expression for hormone receptors while higher grade of tumor showed more negative expression for hormone receptors. This proved an inverse relationship of BR grade with expression of ER and PR receptor.

Sensitivity was 100% while specificity was 81.58% observed. At the same time, the positive predictive value was 79.41%, negative predictive value was 100%, and accuracy was 89.23% for ER [Table 5].
Table 5: Categorization of cases according to Allred (Quick) and H scoring system for estrogen receptor

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Sensitivity was 52.17% while specificity was 100% observed. At the same time, the positive predictive value was 100%, negative predictive value was 79.25%, and accuracy was 83.07% for PR [Table 6].
Table 6: Categorization of cases according to Allred (Quick) and H scoring system for progesterone receptor

Click here to view


According to Pearson's correlation matrix, it was observed that a statistical significant correlation was found between Allred (quick) and H scoring system for both ER and PR and had an equivalent value for ER and PR (P < 0.0001).


  Discussion Top


Medical advances have made carcinoma of breast curable which was thought to be an irremediable condition earlier. Chances of survival have increased due to the remarkable advances in the screening methods, early diagnosis, and innovations in treatments. Breast malignancy is a hormone dependent tumor. Endocrine therapy is very helpful in those tumors which do express the estrogen and progesterone receptor. Hormone receptor analysis is prerequisite now a day before starting adjuvant therapy since it is easier to perform and it also has higher sensitivity.

In the present study, the mean age of presentation was found to be 53.32 ± 12.95 with a range of 21–80 years. This mean age was found to be same in other studies by Mudduwa et al.[14] (52.50 years), Pathak et al.[15] (48 years), Khanna and Rigvardhan[16] (54 years), Jadhav et al.[17] (51.50 years), Rai et al.[18] (49.90 years) and Eifi et al.[19] (48 ± 11 years).

In the present study, Grade II tumor constitutes the highest number of cases at 73.85% followed by Grade I and then Grade III. Similar findings were seen in Chinnam et al.[20] and Jadhav et al.[17] while the rest of the two studies done by Khanna and Rigvardhan[16] and Siadati et al.[21] showed more cases had tumor Grade II followed by Grade III and then Grade I.

Prior, breast cancer women were subjected to hormonal therapy blindly however, majority of patients not responded to the treatment since they do not express ER and PR. As a result, they did not take any advantage from hormonal therapy. Hence, ER/PR status estimation is widely accepted in detecting treatment modality.

In the present study, 46.16% of cases belonged to the ER(−)/PR(−) group followed by 35.38% cases of ER(+)/PR(+) group and rest 18.46% cases of ER(+)/PR(−) group. Similar types of finding were found in other studies as well, i.e., Chinnam et al.[20] and Jadhav et al.[17]

The present study confirms that hormone receptor expression of ER and PR is significantly associated with tumor grade. This finding can have profound impact in breast cancer treatment, suggesting that ER(+)/PR(+) cases should be considered for hormonal therapy than ER(+)/PR(−) and ER(−)/PR(+) patients. Additionally, patients who had ER(+)/PR(+) status revealing hormonal therapy have the advantage of avoiding tumor relapse leading to a good long term survival. Therefore, it is necessary to detect ER/PR status for evaluating the survival of patients and to select their treatment.

In the present study, Grade II tumor was predominant and the proportion of patients expressing ER(+)/PR(+) and ER(−)/PR(−) were most frequent subtype which was approximately comparable with the results reported by Geethamala et al.,[22] Eifi et al.,[19] and Jadhav et al.[17] A statistical analysis was evaluated between ER and PR status and tumor grade with P < 0.0001 was calculated and considered a statistically significant.

Palmer et al.[23] also identified that ER(−)/PR(−) subtype is greatly aggressive and resistant to the hormonal therapy.

There are so many inherent reasons of the large frequency of ER(−)/PR(−) subtype which could be explained by a deficiency of preanalytical factors mainly the fixation quality that investigated by Werner et al.[24] and Goldstein et al.[25] Hence, multidisciplinary cooperation between oncologist, radiologist, and pathologist is required to have sampled breast tissues fixed within the allotted time (6–18 h) to preserve hormonal receptor epitopes.

In the present study, ER(−)/PR(+) subtype accounting 0% which is identical to that reported by Jadhav et al.;[17] however, it differs from that of Eifi et al.[19] who listed 03.97% and 0.99% of Grade II and Grade III tumor.

Hefti et al.[26] had found that ER(−)/PR(+) group does not represent a subtype of biologically distinct or clinically important cancer and so should be considered as a false negative. This artifact subtype results from an inappropriate fixation leading to the loss of epitopes of paraffin embedded breast tissue blocks.

In the present study, ER/PR expression status was calculated by two scoring methods, i.e., Allred (Quick) and H Scoring System.

The Allred score for both ER and PR were analyzed against BR grading system and statistically inverse correlation was found (P = 0.0042 for ER and P = 0.005 for PR). This finding was observed to be similar with other studies, i.e., Mudduwa,[14] Rai et al.,[18] and Khanna and Rigvardhan.[16]

Similarly, H score for both ER and PR were analyzed against BR grading system and statistically inverse correlation was found between H score and BR grading system [P = 0.0017 for ER and P = 0.045 for PR]. This finding was observed approximately similar with the findings of Siadati et al.[21]

Initially, McCarthy's H scoring system was in wide use but recently Allred (Quick) scoring system has been introduced and has gained wide acceptance and clinically validated scoring system but there are many centers those still use this H score system. However, it should be noted that two systems are not strictly equivalent. There are cases that would be considered weakly positive by Allred but negative by H score. So, there are several centers involved in clinical trials for using H score and Allred score system and tried to convert one score system into another to get the results.

But, it is still uncertain whether the results obtained by these methods are comparable and can be interchangeably used. Till now, only one attempt had been done by Shousha[27] to make two popular methods, i.e., Allred and H score, appears equivalent using a conversion table as stated in Vijayashree et al.[28]

In the present study, Allred and H score system were tried to compare with each other when using same immunohistochemical technique with the help of Pearson's correlation matrix. But, there were a small discrepancies found between them for defining ER and PR positivity. It was mainly observed in 1%–10% of positively stained cells. This finding was approximately comparable with other studies, i.e., Brouckaert et al.,[29] Qureshi amnd Pervez,[30] and Vijayashree et al.[28]

This discordance may also result by assessing staining intensity visually. This is susceptible to subjective variation and may lead to interobserver differences in the interpretation of results. In the present study, a Pearson's correlation matrix was used and there was a statistically significant correlation found between them suggesting that Allred (quick) score had an equivalent value to the H score when using same immunohistochemical technique.

The present study has shown that there is no difference between Allred (quick) score and H score system, suggesting that both the scoring system can be used for the assessment of hormone receptor.

After correlating our findings with the findings by Brockaert et al.[29] we recommend that any one method can be used even though Allred Scoring system is widely accepted.


  Conclusion Top


The present study had shown that there was no difference between Allred (quick) and H score system and had a good correlation with Bloom-Richardson grading system. As Allred [quick] scoring system is a standard scoring system and accepted worldwide because it has a valid approach, more accurate and reliable method. But, our study found a good correlation between the both scoring systems. Both being semi-quantitative methods can be practiced regularly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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