Assessment of Estrogen receptor Expression in Carcinoma Breast cases presenting to a tertiary care hospital in Andhra Pradesh

Address for correspondence Dr. C. Srikanth Reddy, Asst. Professor of Surgery, S.V.Medical College & S.V.R.R.G.G.Hospital, Tirupati, Andhra Pradesh, India. * 8 S.V.Medical College & S.V.R.R.G.G.Hospital, Tirupati, Andhra Pradesh, India. Asian Journal of Health Sciences Original Article Asian J Health Sci |Jul -Dec 2014|Vol-2 | Issue2 Proportion Score % of Positive Cells 0 0 1 <1 2 1-10 3 11-33 4 34-66 5 67-100 Intensity Score Intensity of Positivity 0 None 1 Weak 2 Intermediate 3 Strong Allred Score The proportion score and intensity score are added together for a total score.Total score: PS+ IS Interpretation: Score of 0-2 as Negative and 3-8 as Positive.


INTRODUCTION
Breast carcinoma is the most common malignant tumor and the leading cause of death, in women, worldwide1.It accounts for 15 % of all cancer deaths2.Various protocols are in use for the assessment of prognosis, and also to assist in planning further management of these cases.Of various parameters, expression of Estrogen receptor (ER) is significant.Estrogen receptors 6 are a group of proteins found inside cells.They are receptors that are activated by the hormone estrogen estradiol).Once activated by estrogen, the estrogen receptor is able to bind to DNA and regulate the activity of many different genes The ERs are regarded to be cytoplasmic receptors in their unliganded state, but research has shown that a fraction of the ERs resides in the nucleus.Since estrogen is a steroidal hormone, it can pass through the phospholipid membranes of the cell, and receptors therefore do not need to be membrane-bound in order to bind with estrogen.In the absence of hormone, estrogen receptors are largely located in the cytosol.
Hormone binding to the receptor triggers a number of events starting with migration of the receptor from the cytosol into the nucleus, dimerization of the receptor, and subsequent binding of the receptor dimer to specific sequences of DNA known as hormone response elements.
The DNA/receptor complex then recruits other proteins that are responsible for the transcription of downstream DNA into mRNA and finally protein that results in a change in cell function.Estrogen and the ERs have also been implicated in ovarian cancer, colon cancer, prostate cancer, and endometrial cancer [1][2][3][4][5].
In India estrogen receptor expression is found to be low.In a study conducted by Tanuja Shet et al [6] hormone receptor expression in India, was found to be low.Their study was undertaken to know percentage of female breast cancers expressing estrogen receptor and progesterone receptor in the locality in different age groups.

MATERIALS AND METHODS
This prospective study of carcinoma breast was carried out in patientsadmitted to SVRRGG Hospital, Tirupati during the period from January 2013 to August 2014.Hundred cases of breast carcinoma were taken into study.
The clinical study done by interviewing, detailed examination and subjecting to relevant investigations and surgeries, depending upon the stage of the disease.Excised specimen is sent for Histopathological examination in 10% formaline.
Reports of light microscopy (Hematoxylin and Eosin) and immunohistochemistry on tumor histology including MBR(Modified Bloom Richardson) grading and Estrogen receptor status was analysed .

METHOD OF REPORTING BY IHC
Cut-off positivity: "Any nuclear immunostaining for ER should be considered as a positive result according to the National Institute of Health consensus, 2000.
A commonly employed threshold for positive results for ER IHC assays in terms of the potential benefit from adjuvant endocrine therapy is 1 % positive tumour cells with a 1+ or greater signal.
ER status is evaluted by immunohistochemistry technique with monoclonal antibodies (DAKO).ER positivity is assessed using Allred Score system.
The Allred score combines the percentage of positive cells and the intensity of the reaction product in most of the specimen.

Allred Score
The proportion score and intensity score are added together for a total score.Total score: PS+ IS Interpretation: Score of 0-2 as Negative and 3-8 as Positive.

RESULTS
Table Estrogen receptor positivity was seen in 35% of cases where as receptor negativity was seen in 65% of cases.32% patients presented with T2 and T3 tumors each.27% presented with T4. 3% cases presented with T1, Pagets and Tx each.81% of T4 tumors are ER negative.61% of T3 tumors are ER negative.53% of T2 tumors are ER negative.chi square is 3.65.p value =0.17 hence not significant.Whereas in T1 tumors, ER status was positive in all the cases, and in Pagets and TX tumors, ER status was negative in all the cases.

CONCLUSION
In the recent years there has been outstanding advances in breast cancer diagnosis and management leading to earlier detection of disease and the development of more effective treatment.This has resulted in improved quality of life with significant decline in breast cancer deaths for those women living with the disease.Prognosis and management of breast cancer are influenced by classic variables such as histologic type and grade, tumor size, lymph node status, status of Estrogen receptors.In this study an attempt was made to understand the correlation of ER status with histopathological grading and clinicopathological parameters.In the present study relatively lower incidence of Estrogen receptor expression was noted, but ER status correlates well with histopathological grading and other clinico-pathological parameters.Higher grade is associated with ER negativity.Hence, the prognosis of Breast carcinoma in this region is likely to be poor, necessitating early diagnosis and intervention, inorder to improve the survival rates.
The 2 scores are added together for a final score with 8 possible values.

Table 3 : Distribution Of Parity Status 5%
patients are nulliparous.20% have more than 4 children.75% have less than 4 children.Nulliparous women had ER negative tumors.Even in multiparous women, ER negativity predominates.

Table 7 : Distribution Of Er Status According To Modified Bloom Richardson Grading Majority
(80%) of grade III tumors are ER negative.Majority of ER positive tumors are grade I. 60% of grade I tumors are ER positive.20 % of grade II tumors are ER positive.Probability is 0.037 which is significant.Majority (80%) of grade II tumors are ER negative.